A prospective analysis of the postoperative and long-term functional outcomes of a novel technique to perform rectal transection during laparoscopic restorative proctectomy and ileal pouch-anal anastomosis.

BACKGROUND: Laparoscopic ileal pouch-anal anastomosis (IPAA) technique is not standardized. An irregular division of the rectum could result in poor functional outcomes and residual diseased mucosa. The aim of the study was to develop a new technique for performing the rectal transection via a laparoscopic approach, and to compare the outcomes of this technique with those of the open surgery IPAA. METHODS: This prospective study included all patients who underwent restorative proctectomy (following a previous subtotal colectomy) for ulcerative colitis in October 2017-November 2020. Rectal division was performed using a 30 mm open linear stapler which was applied laparoscopically across the distal rectum. Postoperative and functional outcomes, length of anal stump and completeness of mucosal removal were compared. Only the patients who had their ileostomy reversed by 31 December 2020 and, therefore, a minimum follow-up of 6 months from the ileostomy closure, were included in the analysis of the functional outcomes and quality of life. RESULTS: There were 207 patients (161 laparoscopic, 46 open). Median age was 43 (18-77) years and 85 patients (41.1%) were male. Major complications (9.3 vs. 8.7%, p = 0.89) including anastomotic leaks (3.7 vs 4.4%, p = 0.84) were similar after laparoscopic and open IPAA. Patients reported a comparable number of bowel movements during the day (6 vs. 7, p = 0.21) and at night (2 vs. 2, p = 0.66), and a similar rate of episodes of incontinence during the previous 6 months (3.7 vs. 4.3%, p = 0.75). The mean Cleveland Global Quality of Life score was also similar (0.79 vs. 0.74, p = 0.35). CONCLUSION: Our technique is safe and reproducible, and replicates the results of the open IPAA, while maintaining the advantages of minimally invasive surgery and avoiding any kind of anal manipulation which could result in poor long-term functional outcomes.

Granular Data: A Rare Submucosal Tumor of the Colon-Case Report and Review of the Literature.

INTRODUCTION: Granular cellular tumors are unusual lesions that can occur in the gastrointestinal tract, where they localize most commonly to the esophagus followed by the colon. AREAS COVERED: We report a case of a young man with a sub-epithelial lesion of the ascending colon, removed by endoscopic submucosal dissection. Histological examination revealed a granular cellular tumor without features of malignancy. We present a systematic review of the English literature evaluating granular cellular tumors of lower gastrointestinal tract. EXPERT COMMENTARY: These tumors are usually asymptomatic and discovered incidentally during endoscopy performed for other reasons. Though their histological behavior is usually benign, 1-2% are malignant. Therefore, it is important that these lesions are excised and adequately pathologically characterized.

Endoscopic Ultrasound-Guided Stented Gastro-Gastrostomy for Strictured Vertical Banded Gastroplasty.

Herein, we make a video presentation of an endoscopic reversal of a strictured vertical banded gastroplasty (VBG), carried out through an endoscopic ultrasonography (EUS)-guided transluminal therapy system, in order to accurately identify the common gastric wall and to allow the application of an endoscopic stent. The operative time was 60 min, and no intraoperative complication was recorded. On postoperative day 1, an upper GI swallow showed the oral contrast easily flowing into the body of the stomach throughout the stent. A semi-solid diet was started on day 1. The postoperative course was uneventful, and the patient was discharged on day 2. At the 3-month follow-up visit, the patient denied further symptoms. The follow-up upper GI swallow and endoscopy showed a patent gastro-gastrostomy and no residual gastric pouch dilation or stagnation of the oral contrast, and the stent was therefore removed. Gastro-gastrostomy by endoscopic stenting appears to be an effective option to relief symptoms in strictured VBG, and EUS guidance has made access to the target structure easier and safer.

TAMIS-Flap Technique: Full-thickness Advancement Rectal Flap for High Perianal Fistulae Performed Through Transanal Minimally Invasive Surgery.

The formation of an advancement rectal flap could be technically demanding in the presence of high perianal of rectovaginal fistula, and the outcomes could be frustrated by the inadequate view, bleeding and a poor exposure through the standard transanal approach. The application of the transanal minimally invasive surgery (TAMIS) to the advancement rectal flap procedure could overcome these difficulties. In the lithotomy position, a partial fistulectomy was performed and the internal opening was closed. A full-thickness flap was mobilized initially through the classic transanal approach. Subsequently, the TAMIS port was inserted and the mobilization of the flap was carried on proximally for as long as required. The laparoscopic visualization allowed a perfect view, a proper orientation of the flap and accurate hemostasis. The TAMIS-flap procedure seems a promising technique to perform a long advancement rectal flap to treat high perianal or rectovaginal fistulae (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A208).

Prepouch Ileitis After Ileal Pouch-anal Anastomosis: Patterns of Presentation and Risk Factors for Failure of Treatment.

BACKGROUND AND AIMS: There is a lack in the literature about prepouch ileitis [PI], in particular regarding risk factors associated with failure of the medical treatment. Aim of the study is to analyse the characteristics of PI patients and to compare those who required surgery with those who were successfully treated with conservative therapy. METHODS: All cases presenting a diagnosis of PI were included and analysed. Patients eventually requiring surgery were compared with those who were managed conservatively, for symptoms of presentation, endoscopic characteristics, and rate of response to medical treatment. A sub-analysis of outcomes based on the final histology was performed. RESULTS: The overall incidence of PI among 1286 patients was 4.4% [57], after a median of 6.8 years from pouch surgery. Symptoms included increased frequency [26.4%], outlet obstruction [21%], and bleeding [15.8%]. Afferent limb stenosis affected 49.1% of patients. The comparison showed that patients requiring surgery had a higher rate of Crohn's disease and indeterminate colitis [42.1 vs 0% and 15.8 vs 2.6%, p < 0.0001], outlet obstruction as main symptom [47.4 vs 7.9%, p = 0.0023], and afferent limb stenosis [73.7 vs 36.8%, p = 0.008] at endoscopy. Rate of failure of medical treatment at 5 years was 8.2% in patients with ulcerative colitis and 75% in the presence of both indeterminate colitis and Crohn's disease [p < 0.0001]. CONCLUSIONS: Crohn's disease, indeterminate colitis, and stenosis with outlet obstruction are risk factors for failure of treatment after diagnosis of PI. Early aggressive therapy and surgery should be considered in these cases.

Barrier effect of Esoxx(®) on esophageal mucosal damage: experimental study on ex-vivo swine model.

The aim of the present study was to assess the potential barrier effect of Esoxx(®), a new nonprescription medication under development for the relief of gastroesophageal reflux symptoms. Esoxx is based on a mixture of hyaluronic acid and chondroitin sulfate in a bioadhesive suspension of Lutrol(®) F 127 polymer (poloxamer 407) which facilitates the product adhesion on the esophageal mucosa. The mucosal damage was induced by 15 to 90 minutes of perfusion with an acidic solution (HCl, pH 1.47) with or without pepsin (2000 U/mL, acidified to pH 2; Sigma-Aldrich). Mucosal esophageal specimens were histologically evaluated and Evans blue dye solution was used to assess the permeability of the swine mucosa after the chemical injury. The results show that: (1) esophageal mucosal damage is related to the perfusion time and to the presence of pepsin, (2) mucosal damage is associated with an increased permeability, documented by an evident Evans blue staining, (3) perfusion with Esoxx is able to reduce the permeability of the injured mucosa, even after saline washing of the swine esophagus. These preliminary results support further clinical studies of Esoxx in the topical treatment of gastroesophageal reflux symptoms.

Hiatus hernia and intrathoracic migration of esophagogastric junction in gastroesophageal reflux disease.

The prevalence and clinical presentation of reducible and irreducible hiatus hernia were investigated within a gastro-esophageal reflux disease patient population. Reflux symptoms and esophagitis data were collected on 791 patients. The barium swallow was used to assess the esophagogastric junction. Clinical and endoscopic findings were tested to predict radiographic findings. The esophagogastric junction was normal in 17% of patients, 53% had a sliding hiatus hernia with a reducible esophagogastric junction; in 23% it was irreducible although axial, and 8% had massive incarcerated hiatus hernia. The presence of reducible sliding hiatus hernia did not influence clinical presentation. Axial irreducibility presented with long-standing severe symptoms and esophagitis in 80% of cases. Clinical and endoscopic findings predicted axial irreducibility in 52% of cases. In conclusion, sliding hiatus hernia with an reducible esophagogastric junction does not influence the severity of gastroesophageal reflux disease. An irreducible esophagogastric junction is associated with long-standing severe gastroesophageal reflux disease. Clinical and endoscopic findings may only be indicative of axial esophagogastric junction irreducibility; thus barium swallow should be part of the work-up.

Radiological examinations in the morpho-functional evaluation of the esophago-gastric junction in gastro-esophageal reflux disease.

PURPOSE: The aim of our paper is to define, on the basis of a long experience, the anatomical and radiological classification of the progressive phases of the axial intrathoracic migration of the esophago-gastric junction (EGJ), through a standardised radiological method that allows precise identification of the anatomical structures involved. MATERIALS AND METHODS: From 1981 to 2001, 1388 patients with gastro-esophageal reflux disease (GERD) were examined by traditional contrast techniques that consisted in taking single contrast radiograms of the patients in different positions after administering a small high-density bolus of barium: with the patient standing up in frontal position, at rest, during forced inspiration, and during straining; standing up in a right front 30 degrees oblique position; and in prone position, in a right posterior 30 degrees oblique projection. On the basis of previous radiological and manometric studies aimed at verifying the diagnostic reliability of the radiological examination [8], the distance of the esophago-gastric junction from the esophageal hiatus was indirectly evaluated in an anterior-posterior projection, according to the criteria introduced by Monges [3]. The sling fibers, which form a radiologically detectable cut at the apex of the angle of His, are the lowest portion of the EGJ. RESULTS: On the basis of the radiological findings, and in agreement with the radiological classifications reported in the literature, we evidenced five groups, with pathologically characteristic signs: - 1(st) group (63%) patients who in orthostatic position have an EGJ regularly placed within the abdomen (16%), and patients with the EGJ regularly placed within the abdomen, but with a small sliding intermittent hiatus hernia (47%); - 2(nd) group (13%) cardial tuberosity malposition; - 3(rd) group (7%) concentric hiatus hernia; - 4(th) group (8%) acquired short esophagus; - 5(th) group (9%) massive incarcerated gastric hiatus hernia. CONCLUSIONS: Traditional radiography, performed with an adequate technique and with the necessary expedients, allows for the correct interpretation of the anatomical disoder called GERD, and is therefore the first diagnostic approach in defining correct patient management.