Durable Approaches to Recurrent Rectal Prolapse Repair May Require Avoidance of Index Procedure.

BACKGROUND: Surgical treatment of recurrent rectal prolapse is associated with unique technical challenges, partially determined by the surgical approach used for the index operation. Success rates are variable, and data to determine the best approach in patients with recurring prolapse are lacking. OBJECTIVE: The study aimed to assess current surgical approaches to patients with prior rectal prolapse repairs and to compare short-term outcomes of de novo and redo procedures, including recurrence of rectal prolapse. DESIGN: Retrospective analysis of a prospective database. SETTINGS: The Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement database. De-identified surgeons at more than 25 sites (81% high volume) self-reported patient demographics, prior repairs, symptoms of incontinence and obstructed defecation, and operative details, including history of concomitant repairs and prior prolapse repairs. PATIENTS: Patients who were offered surgery for full thickness rectal prolapse. INTERVENTIONS: Incidence and type of repair used for prior rectal prolapse surgery were recorded. Primary and secondary outcomes of index and redo operations were calculated. Patients undergoing rectal prolapse re-repair (redo) were compared with patients undergoing first (de novo) rectal prolapse repair. The incidence of rectal prolapse recurrence in de novo and redo operations was quantified. OUTCOMES: The primary outcome of rectal prolapse recurrence in de novo and redo settings. RESULTS: Eighty-nine (19.3%) of 461 patients underwent redo rectal prolapse repair. On short-term follow-up, redo patients had prolapse recurrence rates similar to those undergoing de novo repair. However, patients undergoing redo procedures rarely had the same operation as their index procedure. LIMITATIONS: Self-reported, de-identified data. CONCLUSION: Our results suggest that recurrent rectal prolapse surgery is feasible and can offer adequate rates of rectal prolapse durability in the short term but may argue for a change in surgical approach for redo procedures when clinically feasible. See Video Abstract . LOS ENFOQUES DURADEROS PARA LA REPARACIN DEL PROLAPSO RECTAL RECURRENTE PUEDEN REQUERIR EVITAR EL PROCEDIMIENTO NDICE: ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal recurrente se asocia con desafíos técnicos únicos, determinados en parte por el abordaje quirúrgico utilizado para la operación inicial. Las tasas de éxito son variables y faltan datos para determinar el mejor abordaje en pacientes con prolapso recurrente.OBJETIVO:Evaluar los enfoques quirúrgicos actuales para pacientes con reparaciones previas de prolapso rectal y comparar los resultados a corto plazo de los procedimientos de novo y rehacer, incluida la recurrencia del prolapso rectal.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.AJUSTE:Base de datos de mejora prospectiva de la calidad del Consorcio multicéntrico de trastornos del suelo pélvico. Cirujanos no identificados en más de 25 sitios (81% de alto volumen) informaron datos demográficos de los pacientes, reparaciones previas, síntomas de incontinencia y defecación obstruida y detalles operativos, incluido el historial de reparaciones concomitantes y reparaciones previas de prolapso.INTERVENCIONES:Se registro la incidencia y el tipo de reparación utilizada para la cirugía de prolapso rectal previa. Se calcularon los resultados primarios y secundarios de las operaciones de índice y reoperacion. Se compararon los pacientes sometidos a una nueva reparación (reoperacion) de prolapso rectal con pacientes sometidos a una primera reparación (de novo) de prolapso rectal. Se cuantificó la incidencia de recurrencia del prolapso rectal en operaciones de novo y rehacer.RESULTADOS:El resultado primario de recurrencia del prolapso rectal en entornos de novo y redo. Ochenta y nueve (19,3%) de 461 pacientes se sometieron a una nueva reparación del prolapso rectal. En el seguimiento a corto plazo, los pacientes reoperados tuvieron tasas de recurrencia de prolapso similares a los de los sometidos a reparación de novo. Sin embargo, los pacientes sometidos a procedimientos de rehacer rara vez tuvieron la misma operación que su procedimiento índice.LIMITACIONES:Datos no identificados y autoinformados.CONCLUSIONES/DISCUSIÓN:Nuestros resultados sugieren que la cirugía de prolapso rectal recurrente es factible y puede ofrecer tasas adecuadas de durabilidad del prolapso rectal en el corto plazo, pero puede abogar por un cambio en el enfoque quirúrgico para rehacer los procedimientos cuando sea clínicamente factible. (Traducción-Dr. Mauricio Santamaria ).

Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study.

BACKGROUND: Patients with IBD are at increased risk of persistent opioid use, wherein surgery plays an important role. OBJECTIVE: Identify risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery and describe in-hospital postoperative opioid treatment. DESIGN: This was a retrospective observational cohort study. ORs for persistent postoperative opioid use were calculated using preoperative and in-hospital characteristics, and in-hospital opioid use was described using oral morphine equivalents. SETTING: This study was conducted at a university hospital with a dedicated IBD surgery unit. PATIENTS: Patients who underwent surgery for IBD from 2017 to 2022 were included. MAIN OUTCOME MEASURES: Our main outcome measure was persistent postoperative opioid use (1 or more opioid prescriptions filled 3-9 months postoperatively). RESULTS: We included 384 patients, of whom 36 (9.4%) had persistent postoperative opioid use, but only 11 (2.9%) of these patients were opioid naive preoperatively. We identified World Health Organization performance status >1 (OR 8.21; 95% CI, 1.19-48.68), preoperative daily opioid use (OR 12.84; 95% CI, 4.78-35.36), psychiatric comorbidity (OR 3.89; 95% CI, 1.29-11.43) and in-hospital mean daily opioid use (per 10 oral morphine equivalent increase; OR 1.22; 95% CI, 1.12-1.34) as risk factors for persistent postoperative opioid use using multivariable regression analysis. LIMITATIONS: Our observational study design and limited sample size because of it being a single-center study resulted in wide CIs. CONCLUSIONS: We identified risk factors for persistent postoperative opioid use in patients undergoing surgery for IBD. Results indicate a need for optimization of pain treatment in patients with IBD both before and after surgery. These patients might benefit from additional opioid-sparing measures. See Video Abstract. FACTORES DE RIESGO EN LA ADMINISTRACION DURADERA DE OPIOIDES EN EL POSTOPERATORIO EN CASOS DE CIRUGA POR ENFERMEDAD INFLAMATORIA INTESTINAL ESTUDIO OBSERVACIONAL DE COHORTES: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de recibir opioides de manera duradera, casos donde la cirugía juega un papel importante.OBJETIVO:Identificar los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII y describir el tratamiento intra-hospitalario con los mismos.DISEÑO:Estudio observacional retrospectivo de cohortes. La relación de probabilidades (odds ratio - OR) en la adminstracion duradera de opioides post-operatorios fué calculada utilizando las características pré-operatorias y hospitalarias, donde la administración de opioides intra-hospitalarios fué descrita con la utilización de equivalentes de morfina oral.AMBIENTE:Estudio realizado en un hospital universitario con una unidad de cirugía dedicada a la EII.PACIENTES:Se incluyeron todos los pacientes sometidos a cirugía por EII entre 2017 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Nuestra principal medida de resultado fué la administración post-operatoria duradera de opioides (≥1 receta completa de opioides entre 3 y 9 meses después de la operación).RESULTADOS:Incluimos 384 pacientes, de los cuales 36 (9,4%) recibieron opioides de manera duradera en el post-operatorio, de los cuales solamente 11 pacientes (2,9%) no habían recibido opioides antes de la operación. Identificamos el estado funcional de la OMS > 1 (OR 8,21, IC 95% 1,19-48,68), el uso diario de opioides pré-operatorios (OR 12,84, IC 95% 4,78-35,36), los casos de comorbilidad psiquiátrica (OR 3,89, IC 95% 1,29-11,43) y el uso medio diario de opioides en el hospital (por cada aumento de 10 equivalentes de morfina oral) (OR 1,22, IC del 95%: 1,12-1,34 como factores de riesgo para la administración de opioides de manera duradera en el post-operatorio mediante el análisis de regresión multivariable.LIMITACIONES:Nuestro diseño de estudio observacional y el tamaño de la muestra limitada debido a que fue un estudio en un solo centro, dando como resultado intervalos de confianza muy amplios.CONCLUSIONES:Se identificaron los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII. Los resultados demuestran la necesidad de optimizar el tratamiento del dolor en pacientes con EII, tanto antes como después de la cirugía. Estos pacientes podrían beneficiarse de medidas adicionales de ahorro de opioides. (Traducción-Dr. Xavier Delgadillo).

A comprehensive scoring system for the better prediction of bowel resection in pediatric intussusception.

BACKGROUND: Intussusception presents a significant emergency that often necessitates bowel resection, leading to severe complications and management challenges. This study aims to investigate and establish a scoring system to enhance the prediction of bowel resection necessity in pediatric intussusception patients. METHODS: This retrospective study analyzed 660 hospitalized patients with intussusception who underwent surgical management at a pediatric hospital in Southwest China from April 2008 to December 2020. The necessity of bowel resection was assessed and categorized in this cohort. Variables associated with bowel resection were examined using univariate and multivariate logistic regression analyses. Based on these analyses, a scoring system was developed, grounded on the summation of the coefficients (ß). RESULTS: Among the 660 patients meeting the inclusion criteria, 218 required bowel resection during surgery. Bowel resection occurrence was linked to an extended duration of symptoms (Odds Ratio [OR] = 2.14; 95% Confidence Interval [CI], 1.03-5.23; P = 0.0015), the presence of gross bloody stool (OR = 8.98; 95% CI, 1.76-48.75, P < 0.001), elevated C-reactive protein levels (OR = 4.79; 95% CI, 1.12-28.31, P = 0.0072), lactate clearance rate (LCR) (OR = 17.25; 95% CI, 2.36-80.35; P < 0.001), and the intussusception location (OR = 12.65; 95% CI, 1.46-62.67, P < 0.001), as determined by multivariate logistic regression analysis. A scoring system (totaling 14.02 points) was developed from the cumulative ß coefficients, with a threshold of 5.22 effectively differentiating infants requiring surgical intervention from others with necrotizing enterocolitis (NEC), exhibiting a sensitivity of 78.3% and a specificity of 71.9%. CONCLUSIONS: This study successfully identified multiple risk factors for bowel resection and effectively used a scoring system to identify patients for optimal clinical management.

MRI-defined T3, clear mesorectal fascia mid-low rectal cancer: is neoadjuvant treatment necessary?

AIM: Neoadjuvant treatments (nCRT) are becoming the standard treatment for patients with stage II or III mid-low rectal cancer. Recently, some studies have shown that surgery alone may be sufficient for patients with T3 rectal cancer. This raises the question of whether nCRT is necessary for all patients with T3 rectal cancer. Therefore, this study compared the clinical outcomes of patients with MRI-defined T3, clear MRF mid-low rectal cancer treated with surgery alone (TME group) or nCRT followed by surgery (nCRT + TME group). METHODS: A total of 1509 patients were enrolled in this study. After a 1:1 propensity score matching analysis, 480 patients were included in each group. The primary endpoint was 3-year disease-free survival (DFS). The secondary endpoints included the perioperative outcomes, histopathologic outcomes, and other follow-up outcomes. RESULTS: nCRT had advantages in rates of sphincter-preserving surgery and tumor downstaging, but it was accompanied by a higher rate of enterostomies. At 3 years after surgery, local recurrence occurred in 3.3% of patients in the TME group and in 3.5% of patients in the nCRT + TME group (P = 0.914), the DFS rates were 78.3% in the TME group and 75.3% in the nCRT + TME group (P = 0.188), and the overall survival rates were 90.3% in the TME group and 89.9% in the nCRT + TME group (P = 0.776). CONCLUSIONS: Surgery alone versus nCRT followed by surgery may provide similar long-term oncological outcomes for patients with MRI-defined T3, clear MRF, and mid-low rectal cancer. nCRT may cause overtreatment in some patients.

Subtotal fistulectomy and sliding anoderm flap: A new sphincter-sparing technique for anal fistula.

AIM: The underlying causes of failure or recurrence after ligation of the intersphincteric fistula tract are postulated to be refistulization, breakdown of the closure wound in the intersphincteric plane and faecal contents entering the internal opening, thereby causing recurrent infection. The aim of this study is to demonstrate the outcomes of subtotal fistulectomy with sliding anoderm flaps to prevent refistulization. METHOD: This retrospective study used prospectively collected data. Patients with transsphincteric or intersphincteric fistulas were enrolled between August 2021 and July 2023. An anal manometric study was performed before and after surgery. Faecal incontinence was evaluated using the faecal incontinence severity index (FISI). Failure was defined as nonhealing of the surgical wound or fistula. RESULTS: Fifty-one patients who underwent subtotal fistulectomy with a sliding anoderm flap were included. After a median follow-up of 12 months (range 4-27 months), primary healing was achieved in 49 patients (96%). Two patients experienced treatment failure, while none developed postoperative recurrence. The median healing time was 10 weeks (range 6-24 weeks). The FISI scores did not change significantly after the surgery. The median resting pressure significantly reduced after surgery [125 cmH2O (range 59-204 cmH2O) vs. 99 cmH2O (range 36-176 cmH2O); p = 0.0001]. The median squeeze pressure significantly decreased after surgery [356 cmH2O (range 137-579 cmH2O) vs. 329 cmH2O (range 72-594 cmH2O; p = 0.005)]. CONCLUSION: Subtotal fistulectomy with a sliding anoderm flap showed excellent healing rates with no postoperative deterioration of anal function.

Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis.

BACKGROUND: The complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts. METHODS: A population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register. RESULTS: During the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery. CONCLUSIONS: The rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.

Introduction of a new surgical robot platform "hinotori™" in an institution with established da Vinci surgery™ for digestive organ operations.

BACKGROUND: New platforms for robotic surgery have recently become available for clinical use; however, information on the introduction of new surgical robotic platforms compared with the da Vinci™ surgical system is lacking. In this study, we retrospectively determined the safe introduction of the new "hinotori™" surgical robot in an institution with established da Vinci surgery using four representative digestive organ operations. METHODS: Sixty-one patients underwent robotic esophageal, gastric, rectal, and pancreatic operations using the hinotori system in our department in 2023. Among these, 22 patients with McKeown esophagectomy, 12 with distal gastrectomy, 11 with high- and low-anterior resection of the rectum, and eight with distal pancreatectomy procedures performed by hinotori were compared with historical controls treated using da Vinci surgery. RESULTS: The console (cockpit) operation time for distal gastrectomy and rectal surgery was shorter in the hinotori group compared with the da Vinci procedure, and there were no significant differences in the console times for the other two operations. Other surgical results were almost similar between the two robot surgical groups. Notably, the console times for hinotori surgeries showed no significant learning curves, determined by the cumulative sum method, for any of the operations, with similar values to the late phase of da Vinci surgery. CONCLUSIONS: This study suggests that no additional learning curve might be required to achieve proficient surgical outcomes using the new hinotori surgical robotic platform, compared with the established da Vinci surgery.

A discrete-event simulation model for assessing operating room efficiency of thoracic, gastrointestinal, and orthopedic surgeries.

BACKGROUND: In hospital management, pinpointing steps that most enhance operating room (OR) throughput is challenging. While prior literature has utilized discrete event simulation (DES) to study specific strategies such as scheduling and resource allocation, our study examines an earlier planning phase, assessing all workflow stages to determine the most impactful steps for subsequent strategy development. METHODS: DES models real-world systems by simulating sequential events. We constructed a DES model for thoracic, gastrointestinal, and orthopedic surgeries summarized from a tertiary Chinese hospital. The model covers preoperative preparations, OR occupation, and OR preparation. Parameters were sourced from patient data and staff experience. Model outcome is OR throughput. Post-validation, scenario analyses were conducted for each department, including: (1) improving preoperative patient preparation time; (2) increasing PACU beds; (3) improving OR preparation time; (4) use of new equipment to reduce the operative time of a selected surgery type; three levels of improvement (slight, moderate, large) were investigated. RESULTS: The first three improvement scenarios resulted in a 1%-5% increase in OR throughput across the three departments. Large reductions in operative time of the selected surgery types led to approximately 12%, 33%, and 38% increases in gastrointestinal, thoracic, and orthopedic surgery throughput, respectively. Moderate reductions resulted in 6%-17% increases in throughput and slight reductions of 1%-7%. CONCLUSIONS: The model could reliably reflect OR workflows of the three departments. Among the options investigated, model simulations suggest that improving OR preparation time and operative time are the most effective.

Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection.

OBJECTIVE: To describe the management of recurrent bowel endometriosis after previous colorectal resection. DESIGN: Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. SETTING: A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. INTERVENTION: Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. CONCLUSION: Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

Incidence and risk factors of bowel dysfunction after minimally invasive rectal cancer surgery and discrepancies between the Wexner score and the low anterior resection syndrome (LARS) score.

PURPOSE: Bowel dysfunction after sphincter-preserving-surgery (SPS) impacts quality of life. The Wexner score (WS) and the low anterior resection syndrome (LARS) score (LS) are instruments for assessing postoperative bowel dysfunction. We analyzed the incidence of and risk factors for each symptom and examined the discrepancies between the two scores. METHODS: A total of 142 patients with rectal cancer, who underwent minimally invasive SPS between May, 2018 and July, 2019, were included. A questionnaire survey using the two scores was given to the patients 2 years after SPS. RESULTS: Tumor location and preoperative radiotherapy were independent risk factors for major LARS. Intersphincteric resection with a hand-sewn anastomosis (HSA) was an independent risk factor for high WS. Among the patients who underwent HSA, 82% experienced incontinence for liquid stools, needed to wear pads, and suffered lifestyle alterations. Of the 35 patients with minor LARS, only 1 had a high WS, and 80.0% reported no lifestyle alterations. Among the 75 patients with major LARS, 58.7% had a low WS and 21.3% reported no lifestyle alterations. CONCLUSION: The results of this study provide practical data to help patients understand potential bowel dysfunction after SPS. The discrepancies between the WS and LS were clarified, and further efforts are required to utilize these scores in clinical practice.

Time-to-surgery paradigms: wait time and surgical outcomes in critically Ill patients who underwent emergency surgery for gastrointestinal perforation.

BACKGROUND: Waiting time for emergency abdominal surgery have been known to be linked to mortality. However, there is no clear consensus on the appropriated timing of surgery for gastrointestinal perforation. We investigated association between wait time and surgical outcomes in emergency abdominal surgery. METHODS: This single-center retrospective cohort study evaluated adult patients who underwent emergency surgery for gastrointestinal perforations between January 2003 and September 2021. Risk-adjusted restricted cubic splines modeled the probability of each mortality according to wait time. The inflection point when mortality began to increase was used to define early and late surgery. Outcomes among propensity-score matched early and late surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). RESULTS: Mortality rates began to rise after 16 h of waiting. However, early and late surgery groups showed no significant differences in 30-day mortality (11.4% vs. 5.7%), ICU stay duration (4.3 ± 7.5 vs. 4.3 ± 5.2 days), or total hospital stay (17.4 ± 17.0 vs. 24.7 ± 23.4 days). Notably, patients waiting over 16 h had a significantly higher ICU readmission rate (8.6% vs. 31.4%). The APACHE II score was a significant predictor of 30-day mortality. CONCLUSIONS: Although we were unable to reveal significant differences in mortality in the subgroup analysis, we were able to find an inflection point of 16 h through the RCS curve technique. TRIAL REGISTRATION: Formal consent was waived due to the retrospective nature of the study, and ethical approval was obtained from the institutional research committee of our institution (B-2110-714-107) on 6 October 2021.

Duhamel and transanal endorectal pull-throughs for Hirschsprung disease: a Bayesian network meta-analysis.

BACKGROUND: To comprehensively compare the effects of open Duhamel (OD), laparoscopic-assisted Duhamel (LD), transanal endorectal pull-through (TEPT), and laparoscopic-assisted endorectal pull-through (LEPT) in Hirschsprung disease. METHODS: PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP were comprehensively searched up to August 4, 2022. The outcomes were operation-related indicators and complication-related indicators. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Network plots, forest plots, league tables and rank probabilities were drawn for all outcomes. For measurement data, weighted mean differences (WMDs) and 95% credibility intervals (CrIs) were reported; for enumeration data, relative risks (RRs) and 95%CrIs were calculated. RESULTS: Sixty-two studies of 4781 patients were included, with 2039 TEPT patients, 1669 LEPT patients, 951 OD patients and 122 LD patients. Intraoperative blood loss in the OD group was more than that in the LEPT group (pooled WMD = 44.00, 95%CrI: 27.33, 60.94). Patients lost more blood during TEPT versus LEPT (pooled WMD = 13.08, 95%CrI: 1.80, 24.30). In terms of intraoperative blood loss, LEPT was most likely to be the optimal procedure (79.76%). Patients undergoing OD had significantly longer gastrointestinal function recovery time, as compared with those undergoing LEPT (pooled WMD = 30.39, 95%CrI: 16.08, 44.94). The TEPT group had significantly longer gastrointestinal function recovery time than the LEPT group (pooled WMD = 11.49, 95%CrI: 0.96, 22.05). LEPT was most likely to be the best operation regarding gastrointestinal function recovery time (98.28%). Longer hospital stay was observed in patients with OD versus LEPT (pooled WMD = 5.24, 95%CrI: 2.98, 7.47). Hospital stay in the TEPT group was significantly longer than that in the LEPT group (pooled WMD = 1.99, 95%CrI: 0.37, 3.58). LEPT had the highest possibility to be the most effective operation with respect to hospital stay. The significantly reduced incidence of complications was found in the LEPT group versus the LD group (pooled RR = 0.24, 95%CrI: 0.12, 0.48). Compared with LEPT, OD was associated with a significantly increased incidence of complications (pooled RR = 5.10, 95%CrI: 3.48, 7.45). Patients undergoing TEPT had a significantly greater incidence of complications than those undergoing LEPT (pooled RR = 1.98, 95%CrI: 1.63, 2.42). For complications, LEPT is most likely to have the best effect (99.99%). Compared with the LEPT group, the OD group had a significantly increased incidence of anastomotic leakage (pooled RR = 5.35, 95%CrI: 1.45, 27.68). LEPT had the highest likelihood to be the best operation regarding anastomotic leakage (63.57%). The incidence of infection in the OD group was significantly higher than that in the LEPT group (pooled RR = 4.52, 95%CrI: 2.45, 8.84). The TEPT group had a significantly increased incidence of infection than the LEPT group (pooled RR = 1.87, 95%CrI: 1.13, 3.18). LEPT is most likely to be the best operation concerning infection (66.32%). Compared with LEPT, OD was associated with a significantly higher incidence of soiling (pooled RR = 1.91, 95%CrI: 1.16, 3.17). Patients with LEPT had the greatest likelihood not to develop soiling (86.16%). In contrast to LD, LEPT was significantly more effective in reducing the incidence of constipation (pooled RR = 0.39, 95%CrI: 0.15, 0.97). LEPT was most likely not to result in constipation (97.81%). LEPT was associated with a significantly lower incidence of Hirschprung-associated enterocolitis (HAEC) than LD (pooled RR = 0.34, 95%CrI: 0.13, 0.85). The OD group had a significantly higher incidence of HAEC than the LEPT group (pooled RR = 2.29, 95%CrI: 1.31, 4.0). The incidence of HAEC was significantly greater in the TEPT group versus the LEPT group (pooled RR = 1.74, 95%CrI: 1.24, 2.45). LEPT was most likely to be the optimal operation in terms of HAEC (98.76%). CONCLUSION: LEPT may be a superior operation to OD, LD and TEPT in improving operation condition and complications, which might serve as a reference for Hirschsprung disease treatment.

Surgical maneuvers for long-segment Hirschsprung pull-through in unique patients.

PURPOSE: Patients with Hirschsprung disease affecting the splenic flexure or more proximal segments present a surgical challenge. Mobilizing the transverse colon to the pelvis during a pull-through may obstruct the distal ileum, or the length may be insufficient to reach the lower pelvis. This retrospective study aimed to describe two surgical techniques that facilitate mobilization of the transverse colon and their outcome. METHODS: We included patients operated on between April 2017 and April 2024 and analyzed sex, comorbidities, type of pull- through, age at pull-through, history of previous surgeries, cause of the proximal transverse colon pull-through, technique used (Deloyers or Turnbull), complications , postoperative outcome and follow-up. The first technique used was the maneuver described by Turnbull. This operation creates a mesenteric defect and mobilizes the colon into this mesenteric window at the distal ileum level. The second technique was described by Deloyers and involves a 180-degree rotation of the right colon by dissecting the right colon attachment and the hepatocolic ligament. The cecum and the ileocecal valve are placed in the right upper quadrant, and the distal colon is mobilized into the pelvis. RESULTS: We included 13 patients, 12 boys and 1 girl. Eight patients had previous surgeries in another hospital: five had an initial transverse colostomy, and three had an ileostomy. The remaining five had the initial operation in our hospital: two had an ileostomy, two had a colostomy, and one had a primary pull-through. The median age at pull-through was 16 months (4-59 months). We used the Turnbull technique in four patients whose aganglionosis was limited to the middle transverse colon. The Deloyers technique was used in the remaining patients, with ganglion cells in the proximal transverse colon. We left a protective ileostomy in five patients. The median follow-up was 4.5 years (3 months to 10 years). The stoma takedown is pending in one patient. CONCLUSION: The Turnbull and Deloyers techniques were helpful in patients with aganglionosis affecting the transverse colon.

Enucleation for intestinal duplications: a comparative study with intestinal resection and anastomosis.

PURPOSE: Duplication enucleation (DE) has been described as an alternative to intestinal resection with primary anastomosis (IRA) for intestinal duplications, but no comparative study exists. The aim of this study was to compare both surgical procedures for intestinal duplication. METHODS: A retrospective study was performed, including all children treated for intestinal duplication (2005-2023). Patients that underwent DE were compared to those that underwent IRA. Statistical significance was determined using p < 0.05. Ethical approval was obtained. RESULTS: A total of 51 patients (median age: 5 months) were treated for intestinal duplication, including 27 patients (53%) that underwent DE and 24 IRA (47%). A cystic image was detected prenatally in 19 patients (70%) with DE and 11 patients (46%) with IRA (p = 0.09). Enucleation was performed using laparoscopy in 7 patients (14%). Patients that underwent DE had shorter time to first feed (1 vs 3 days, p = 0.0001) and length of stay (4 vs 6 days, p < 0.0004) compared to IRA. A muscular layer was identified in 68% of intestinal resection specimens. CONCLUSION: Compared to intestinal resection with anastomosis, duplication enucleation is associated with decreased postoperative length of stay and delay to first feeds without increasing post-operative complications. Regarding histological analysis, enucleation seems feasible in most cases.

The use of postoperative calibrations in Hirschsprung disease: a practice to reconsider?

PURPOSE: Daily postoperative anal dilations after endorectal pull-through for Hirschsprung disease (HD) are still considered a common practice. We analyzed the potential risks of this procedure and its effectiveness compared to a new internal protocol. METHODS: All infants (< 6 months of age) who underwent transanal endorectal pull-through between January 2021 and January 2023 were prospectively enrolled in a new postoperative protocol group without daily anal dilations (Group A) and compared (1:2 fashion) to those previously treated by postoperative anal dilations (Group B). Patients were matched for age and affected colonic tract. Patients with associated syndromes, extended total intestinal aganglionosis, and presence of enterostomy were excluded. Outcomes considered were: anastomotic complications (stenosis, disruption/leakage), incidence of enterocolitis, and constipation. RESULTS: Eleven patients were included in group A and compared to 22 matched patients (group B). There were no significant differences in the occurrence of anastomotic complications between the two groups. We found a lower incidence of enterocolitis and constipation among group A (p = 0.03 and p = 0.02, respectively). CONCLUSION: A non-dilation strategy after endorectal pull-through could be a feasible alternative and does not significantly increase the risk of postoperative anastomotic complications. Moreover, some preliminary advantages such as lower enterocolitis rate and constipation should be further investigated.

[Technique of Colon Interposition for Oesophageal Replacement for Oesophageal Cancer]. / Technik der Koloninterposition zum Ösophagusersatz beim Ösophaguskarzinom.

Nowadays, it is only relatively rare and in selected situations that colonic interposition is chosen rather than the stomach as a reconstructive organ for replacing the oesophagus. The colon is a reliable organ for tubular replacement of the oesophagus when the stomach is not available for reconstruction. Colon interposition is a complex and complicated operation. It requires a specific indication and thorough preoperative preparation. From a technical point of view, colon interposition places high demands on the selection and surgical dissection of the vascular supply to the reconstructed organ. The reconstruction route and elevation of the interposition graft to the proximal oesophagus and the need to create 3 or 4 gastrointestinal anastomoses also place significantly higher demands than reconstruction using a gastric tube. Overall, despite the significant surgery-related morbidity, good functional results and a good quality of life can usually be achieved. The surgical technique applied in our own practice is described in detail. An overview from literature on the results of colonic interposition is given, particularly with regard to surgical complications and quality of life after colon interposition.

The effect of preoperative mechanical bowel preparation in paediatric bowel surgery on postoperative wound related complications: A meta-analysis.

Mechanical bowel preparation (MBP), a routine nursing procedure before paediatric bowel surgery, is widely should in clinical practice, but its necessity remains controversial. In a systematic review and meta-analysis, we evaluated the effect of preoperative MBP in paediatric bowel surgery on postoperative wound-related complications in order to analyse the clinical application value of MBP in paediatric bowel surgery. As of November 2023, we searched four online databases: the Cochrane Library, Embase, PubMed, and Web of Science. Two investigators screened the collected studies against inclusion and exclusion criteria, and ROBINS-I was used to evaluate the quality of studies. Using RevMan5.3, a meta-analysis of the collected data was performed, and a fixed-effect model or a random-effect model was used to analyse OR, 95% CI, SMD, and MD. A total of 11 studies with 2556 patients were included. Most of studies had moderate-to-severe quality bias. The results of meta-analysis showed no statistically significant difference in the incidence of complications related to postoperative infections in children with MBP before bowel surgery versus those with No MBP, wound infection (OR 1.11, 95% CI:0.76 ~ 1.61, p = 0.59, I2 = 5%), intra-abdominal infection (OR 1.26, 95% CI:0.58 ~ 2.77, p = 0.56, I2 = 9%). There was no significant difference in the risk of postoperative bowel anastomotic leak (OR 1.07, 95% CI:0.68 ~ 1.68, p = 0.78, I2 = 12%), and anastomotic dehiscence (OR 1.67, 95% CI:0.13 ~ 22.20, p = 0.70, I2 = 73%). Patients' intestinal obstruction did not show an advantage of undergoing MBP preoperatively, with an incidence of intestinal obstruction (OR 1.95, 95% CI:0.55 ~ 6.93, p = 0.30, I2 = 0%). Based on existing evidence that preoperative MBP in paediatric bowel surgery did not reduce the risk of postoperative wound complications, we cautiously assume that MBP before surgery is unnecessary for children undergoing elective bowel surgery. However, due to the limited number of study participants selected for this study and the overall low quality of evidence, the results need to be interpreted with caution. It is suggested that more high quality, large-sample, multicenter clinical trials are required to validate our findings.

Intraoperative bowel perfusion assessment methods and their effects on anastomotic leak rates: meta-analysis.

BACKGROUND: Anastomotic leak is one of the most feared complications of colorectal surgery, and probably linked to poor blood supply to the anastomotic site. Several technologies have been described for intraoperative assessment of bowel perfusion. This systematic review and meta-analysis aimed to evaluate the most frequently used bowel perfusion assessment modalities in elective colorectal procedures, and to assess their associated risk of anastomotic leak. Technologies included indocyanine green fluorescence angiography, diffuse reflectance spectroscopy, laser speckle contrast imaging, and hyperspectral imaging. METHODS: The review was preregistered with PROSPERO (CRD42021297299). A comprehensive literature search was performed using Embase, MEDLINE, Cochrane Library, Scopus, and Web of Science. The final search was undertaken on 29 July 2022. Data were extracted by two reviewers and the MINORS criteria were applied to assess the risk of bias. RESULTS: Some 66 eligible studies involving 11 560 participants were included. Indocyanine green fluorescence angiography was most used with 10 789 participants, followed by diffuse reflectance spectroscopy with 321, hyperspectral imaging with 265, and laser speckle contrast imaging with 185. In the meta-analysis, the total pooled effect of an intervention on anastomotic leak was 0.05 (95 per cent c.i. 0.04 to 0.07) in comparison with 0.10 (0.08 to 0.12) without. Use of indocyanine green fluorescence angiography, hyperspectral imaging, or laser speckle contrast imaging was associated with a significant reduction in anastomotic leak. CONCLUSION: Bowel perfusion assessment reduced the incidence of anastomotic leak, with intraoperative indocyanine green fluorescence angiography, hyperspectral imaging, and laser speckle contrast imaging all demonstrating comparable results.

Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study.

BACKGROUND: Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids. OBJECTIVE: This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. DESIGN: Multicenter retrospective study. SETTINGS: Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study. PATIENTS: Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period. MAIN OUTCOME MEASURES: The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up. RESULTS: Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device. LIMITATIONS: The retrospective design and the self-reported nature of data from different centers. CONCLUSIONS: Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).

Stapled Antimesenteric Functional End-to-End Anastomosis Following Intestinal Resection for Crohn's Disease.

BACKGROUND: Anastomotic recurrence after bowel resection is problematic in patients with Crohn's disease. Antimesenteric functional end-to-end handsewn (Kono-S) anastomosis is associated with a low risk of anastomotic recurrence in patients with Crohn's disease. IMPACT OF INNOVATION: Kono-S anastomosis is effective but may be time-consuming. This study aimed to describe stapled antimesenteric functional end-to-end anastomosis for patients with Crohn's disease. TECHNOLOGY MATERIALS AND METHODS: The mesentery of the affected bowel segment was divided. A 5-cm-wide stapled functional end-to-end anastomosis was performed approximately 6 cm from the affected segment. The bowel was divided transversely exactly 90° to the intestinal lumen and the mesentery, and a supporting column was then constructed. PRELIMINARY RESULTS: From January 2018 to June 2021, 17 stapled antimesenteric functional end-to-end anastomoses were performed. The mean operative time was 106 (range, 80-135) minutes, and the time to construct the stapled antimesenteric functional end-to-end anastomosis was 21 (range, 18-28) minutes. The mean follow-up time was 8.9 (range, 1-15) months. In total, 10 patients underwent surveillance endoscopy. The average Rutgeerts score was 0.8 (range, 0-4), and the incidence of endoscopic recurrence was 11.8%. No postoperative mortality or anastomotic leakage was observed. CONCLUSION: Stapled antimesenteric functional end-to-end anastomosis may be a safe and time-saving procedure for patients with Crohn's disease. FUTURE DIRECTIONS: Further prospective studies with a large sample size are warranted.