Posterior component separation with transversus abdominis muscle release versus mesh-only repair in the treatment of complex ventral-wall hernia: a randomized controlled trial.

BACKGROUND: Complex ventral hernias (VHs) represent a real challenge to both general and plastic surgeons. This study aims to compare Sublay Mesh-Only Repair to Posterior Component Separation "PCS" with Transversus Abdominis Release "TAR" in the treatment of complex ventral-wall hernias (VHs). METHODS: This a randomized, controlled, intervention, including two parallel groups: A; Sublay Mesh-Only Repair and Group B; "TAR". Consecutive patients of both genders aged between 18 and 65 years old with complex VHs presented at Mansoura University Hospitals including large-sized abdominal-wall hernia ≥ 10 cm in width, loss of domain ≥ 20%, multiple hernial defects, or recurrent hernias. Immuno-compromised patients, patients with liver impairment, or severe heart failure were considered an exclusion criterion. The primary outcome is the recurrence rate after 12-months following the procedure. RESULTS: Fifty-six patients were recruited in this study. There was no significant difference between both groups regarding recurrence. However, there was significant differences between both groups regarding seroma favoring mesh-only repair. CONCLUSIONS: Although TAR may be associated with longer operative times and more blood losses, these were not found to be statistically significant. Postoperative complication, except for seroma, and recurrence rates were comparable in both groups. Trail registration The study was registered on clicaltrials.gov "NCT04516031".

Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study.

BACKGROUND: Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. METHODS: One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. RESULTS: The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. CONCLUSION: ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.

Anastomotic leakage following laparoscopic resection of low and mid rectal cancer.

PURPOSE: Anastomotic leakage is considered the commonest major complication after surgery for rectal cancer. MATERIALS AND METHODS: Patients who underwent laparoscopic LAR or ULAR for rectal cancer were recruited. The primary outcome was the incidence of the AL during 30 days postoperative. RESULTS: Fifty-nine consecutive patients were included in the study. Fifty-three patients underwent LAR with stapled colorectal anastomoses, while the remaining 6 patients underwent ULAR with hand-sewn coloanal anastomoses. The median duration of operation was 195 minutes (range; 120-315). The defunctioning ileostomy was created in 24 (7%) patients. Overall, there was no recorded mortality. Only 10 (17%) patients developed complications. There were only 4 patients who developed AL. Three patients had a subclinical AL as they had defunctioning ileostomy at the time of the initial procedure, the diagnosis was made by CT with rectal contrast. They were treated conservatively with transanal anastomotic drainage under endoscopic guidance. One patient had a clinically significant AL, demonstrated as a peritonitis. This patient required reoperation during which pelvic abscess was drained, resection of the previous anastomosis, and hartmann's colostomy was performed. CONCLUSION: Standardization of a definition, as well as, criteria for the diagnosis of AL, will help in comparison of the results and the surgical techniques in order to optimize the required care offered to rectal cancer patients. On expert hands, it is feasible to perform a laparoscopic sphincter-saving total mesorectal excision, additionally, it provides the advantages of a clear view of the deep pelvis and facilitates a precise sharp dissection. KEY WORDS: Anastomosis, Anastomotic Leakage, Rectal cancer, Total mesorectal excision.

Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection.

PURPOSE: We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL). METHODS: Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL. RESULTS: Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20-35 kg/m2 ). The median tumor distance from the anal verge was 8 cm (range, 4-12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation. CONCLUSION: These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.

Impact of Botulinum Neurotoxin Pyloric Injection During Laparoscopic Sleeve Gastrectomy on Postoperative Gastric Leak: a Clinical Randomized Study.

BACKGROUND: The most frequent and most feared complication after laparoscopic sleeve gastrectomy (LSG) is gastric leak (GL). We hypothesize that botulinum neurotoxin (botulinum type A (BTX-A)) injection into the pyloric sphincter muscle at the time of operation may decrease the risk of postoperative GL. METHODS: Consecutive patients with morbid obesity (MO) treated by LSG were enrolled. Patients were randomly allocated into two groups: group I (intrapyloric BTX-A injection was performed) and group II (no injection was performed). The primary outcome measure was number of patients developing GL. Secondary outcome measures were percent of excess weight loss, postoperative complications, and their management. RESULTS: One hundred and fifteen patients (86 (74.8 %) females) were randomized into two groups of 57 patients (group I) and 58 patients (group II). Four patients in group II developed GL versus no patient in group I (P = 0.04). Ten patients in group I and two in group II developed refractory epigastric pain (P = 0.01). Other complication rates were comparable for both groups. Mean preoperative BMI of patients in both groups had significantly decreased from 54.64 ± 6.82 to 42.99 ± 5.3 at 6 months and to 39.09 ± 5.14 at 12 months (P < 0.001). CONCLUSIONS: LSG is an effective, safe, and minimally invasive procedure for treatment of MO. No patient in whom pyloric BTX-A injection was performed developed postoperative GL versus four patients in whom injection was not performed. The difference in GL rate was statistically significant, thus favoring the use of pyloric BTX-A injection during LSG.

Is LigaSure a safe cystic duct sealer? An ex vivo study.

BACKGROUND: To compare the efficacy and safety of both mechanical methods (clips) and electrosurgical instruments, harmonic scalpel (HS) and LigaSure (LS), for securing the cystic duct during laparoscopic cholecystectomy (LC). METHODS: During the study period from October 2010 to October 2012, 458 patients with gallbladder stones underwent LC. A total of 38 patients were excluded from the study for different reasons. The gallbladder was excised laparoscopically through the traditional method. The gallbladder specimens of the patients were divided into three equal groups randomly, and the distal part of the cystic duct was sealed ex vivo using ligaclips (Group A), HS (Group B), and LS (Group C). The gallbladders were then connected to a pneumatic tourniquet device and we very gradually increased the pressure with air. The bursting pressure of the cystic duct (CDBP) was measured and differences between the three groups were calculated. RESULTS: The mean CDBP was 329.7 ± 38.8 mmHg in the ligaclip group, 358.0 ± 33.1 mmHg in the HS group, and 219.7 ± 41.2 mmHg in the LS group. A comparison of the mean CDBP between the groups indicated the superiority of HS over ligaclip and LS. CDBP was significantly higher in the ligaclips group compared with the LS group (p <0.001). HS and ligaclips were found to be safe sealers as their mean CDBP was found to be higher (>195 mmHg) than the maximum common bile duct pressure, whereas for LS the CDBP range was 150-297 mmHg, indicating that it is not safe for sealing. CONCLUSION: HS is a safe alternative to clips. In fact, it was even safer than clips. By contrast, LS is not safe for cystic duct sealing.

Impact of extent of antral resection on surgical outcomes of sleeve gastrectomy for morbid obesity (a prospective randomized study).

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a surgical technique that treats morbid obesity. METHODS: Consecutive patients with morbid obesity treated by LSG at our department were evaluated. Patients enrolled in the study were randomized into group I (LSG begins the division 2 cm from the pylorus) and group II (LSG begins the division 6 cm from the pylorus). The primary outcome measure was the percent of excess weight loss (% EWL); secondary outcomes included postoperative morbidity and mortality and improvement of comorbidity. RESULTS: One hundred five patients (79 (75.2 %) were females) were randomized into two groups of (GI) 52 patients and (GII) 53 patients. In group I, the mean % EWL was 51.8 ± 13.9, 63.8 ± 16.1 and 71.8 ± 12; however, in group II, the mean % EWL was 38.3 ± 10.9, 51.9 ± 13.6 and 61 ± 11.1 at 6, 12, and 24 months, respectively (P = 0.0001, 0.0001, 0.003). There was weight regain after 2 years in five patients in group II and only one patient in group I (P = 0.09). There was no significant difference between both group as regards gastric leakage, vomiting or GER. There was significant improvement in comorbidity after LSG in both groups, but no significant difference between them. Hospital mortality occurred in group II in one case as a result of gastric leakage. CONCLUSIONS: LSG is a safe and effective procedure with good short-term outcome. Increasing the size of the resected antrum is associated with better weight loss without increasing the rate of complications significantly.

Comparative study of the house advancement flap, rhomboid flap, and y-v anoplasty in treatment of anal stenosis: a prospective randomized study.

PURPOSE: Anal stenosis represents a technical challenge for surgical management. We compared the effects of house flap, rhomboid flap, and Y-V anoplasty procedures in a randomized study in patients with anal stenosis. METHODS: Consecutive patients treated for anal stenosis at our institution were evaluated for inclusion. Participants were randomly allocated to receive house flap, rhomboid flap, or Y-V anoplasty. Follow-up visits were after 1 week, 1 month, 6 months, and 1 year. Study variables included caliber of the anal canal (measured with a conical calibrator), clinical improvement, patient satisfaction (visual analog scale), incontinence (Pescatori incontinence scale), and quality of life (GI Quality of Life Inventory). RESULTS: : Sixty patients with anal stenosis were randomized and completed the study. Operative time was 62 +/- 10 minutes for house flap, 44 +/- 13 minutes for rhomboid flap, and 35 +/- 9 minutes for Y-V anoplasty (P = .042). At 1 year, anal caliber was 23.9 +/- 2.33 mm for house flap, 18.1 +/- 2.05 mm for rhomboid flap, and 16.4 +/- 2.05 mm for Y-V anoplasty (P = .04), with a highly significant increase for the house flap (P = .001). The groups differed significantly regarding clinical improvement at 1 month (95% for house flap, 80% for rhomboid flap, and 65% for Y-V anoplasty, P = .01) and differences persisted at 1 year. Significant differences were seen among groups at 1 year in GI Quality of Life Inventory scores (P = .03), with significant improvement only for the house flap (P = .01). CONCLUSION: Anal stenosis can be effectively managed with the house flap procedure, with the sole disadvantage of longer operative time. Although all 3 procedures are simple and easy to perform, the house flap appears to produce the greatest clinical improvement, patient satisfaction, and improvement in quality of life, with the fewest complications.

Comparative study between biofeedback retraining and botulinum neurotoxin in the treatment of anismus patients.

PURPOSE: Anismus is a significant cause of chronic constipation. This study came to revive the results of BFB training and BTX-A injection in the treatment of anismus patients. MATERIALS AND METHODS: Forty-eight patients with anismus (33 women; mean age 39.6 +/- 15.9) were included in this study. All patients fulfilled Rome II criteria for functional constipation. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography (EMG) activity of the EAS. All patients had non-relaxing puborectalis muscle. The patients were randomized into two groups. Group I patients received biofeedback therapy, two times per week for about 1 month. Group II patients were injected with BTX-A. Follow-up was conducted weekly in the first month then monthly for about 1 year. RESULTS: In the BFB training group, three patients quit before the end of sessions with no improvement; initial improvement was recorded in 12 patients (50%) while long-term success was recorded in six patients (25%). In the BTX-A group, clinical improvement was recorded in 17 patients (70.83%), but the improvement persisted only in eight patients (33.3%). There is a significant difference between BTX-A group and BFB group regarding the initial success, but this significant difference disappeared at the end of follow-up. Manometric relaxation was achieved significantly post-BFB and post-BTX-A injection with no significant difference between the two groups. CONCLUSIONS: Biofeedback training has a limited therapeutic effect on patients suffering from anismus. BTX-A injection seems to be successful for temporary treatment of anismus.

Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases.

AIM: To study the results for the treatment of symptomatic hemorrhoids using rubber band ligation (RBL) method. METHODS: A retrospective study for 750 patients who came to the colorectal unit from June, 1998 to September, 2006, data was retrieved from archived files. RBL was performed using the Mc Gown applicator on an outpatient basis. The patients were asked to return to out-patient clinic for follow up at 2 wk, 1 mo, 6 mo and through telephone call every 6 mo for 2 years). RESULTS: After RBL, 696 patients (92.8%) were cured with no difference in outcome for second or third degree hemorrhoids (P = 0.31). Symptomatic recurrence was detected in 11.04% after 2 years. A total of 52 patients (6.93%) had 77 complications from RBL which required no hospitalization. Complications were pain, rectal bleeding and vaso-vagal symptoms (4.13%, 4.13% and 1.33% of patients, respectively). At 1 mo there were a significant improvement in mean SF-36 scores over baseline in five items, while after 2 years there were improvement in all items over baseline, but not significant. No significant manometeric changes after band ligation. CONCLUSION: RBL is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an out patient procedure with significant improvement in quality of life. RBL doesn't alter ano-rectal functions.