Managing a Misdiagnosed Case of Nevus Sebaceous.

A male patient in his early 20s presented to our outpatient clinic, having previously been misdiagnosed and unsuccessfully treated as a case of viral warts. Dermoscopic and histopathological evaluations revealed characteristic features of the nevus sebaceous. The lesion was eventually treated with an erbium-doped yttrium aluminum garnet (Er:YAG) laser after the patient declined surgical excision. Nevus sebaceous often presents with verrucous surfaces that make misdiagnosis common. A correct diagnosis is crucial due to potential neoplastic transformations. Histopathological analysis is essential for both the confirmation of disease and the exclusion of malignancy. Full-thickness surgical excision remains the preferred treatment.

Modulating the hAM/PCL Biocomposite for Expedited Wound Healing: A Chemical-Free Approach for Boosting Regenerative Potential.

There is an arising need for effective wound dressings that retain the bioactivity of a cellular treatment, but without the high costs and complexities associated with manufacturing, storing, and applying cell-based products. As skin wound recovery is a dynamic and complicated process, a significant obstacle to the healing of skin wounds is the lack of an appropriate wound dressing that can imitate the microenvironment of healthy skin and prevent bacterial infection. It requires the well-orchestrated integration of biological and molecular events. In this study, we have fabricated full-thickness skin graft biocomposite membranes to target full-thickness skin excision wounds. We reinforced human amniotic membrane (hAM) with electrospun polycaprolactone (PCL) to develop composite membranes, namely, PCL/hAM and PCL/hAM/PCL. Composite membranes were compared for physical, biological, and mechanical properties with the native counterpart. PCL/hAM and PCL/hAM/PCL displayed improved stability and delayed degradation, which further synergically improved the rapid wound healing property of hAM, driven primarily by wound closure analysis and histological assessment. Moreover, PCL/hAM displayed a comparable cellular interaction to hAM. On application as a wound dressing, histological analysis demonstrated that hAM and PCL/hAM promoted early epidermis and dermis formation. Studies on in vivo wound healing revealed that although hAM accelerates cell development, the overall wound healing process is similar in PCL/hAM. This finding is further supported by the immunohistochemical analysis of COL-1/COL-3, CD-31, and TGF-ß. Overall, this conjugated PCL and hAM-based membrane has considerable potential to be applied in skin wound healing. The facile fabrication of the PCL/hAM composite membrane provided the self-regenerating wound dressing with the desired mechanical strength as an ideal regenerative property for skin tissue regeneration.

Topical delivery of mupirocin calcium nanostructured lipid carriers using a full-thickness excision wound healing model.

OBJECTIVE: Treatment of contaminated wounds represents a significant challenge in healthcare and there is a need to develop approaches maximising skin retention to maintain therapeutic concentrations of anti-infectives at the wound site. The objective of the present study was to develop and evaluate mupirocin calcium nanolipid emulgels to enhance wound healing performance and patient acceptability. METHODS: Nanostructured lipid carriers (NLCs) of mupirocin calcium were prepared by the phase inversion temperature method using Precirol ATO 5 (Gattefosse, India) and oleic acid as lipids and Kolliphor RH 40 (BASF, India) as surfactant and further incorporated into a gel base for topical delivery. RESULTS: The particle size, polydispersity index and zeta potential of mupirocin NLCs were found to be 128.8±1.25nm, 0.283±0.003 and -24.2±0.56mV, respectively. In vitro release studies from developed emulgel showed sustained drug release over 24 hours. Ex vivo drug permeation studies through excised rat abdominal skin showed better skin permeation (1712.38±15. 57µg/cm2) from developed emulgel compared to marketed ointment (827.92±21.42µg/cm2) after 8 hours, which was in agreement with in vitro antibacterial activity. Studies on Wistar rats indicated the nonirritant potential of developed emulgels. Further, mupirocin emulgels showed improved efficacy in percent wound contraction of acute contaminated open wounds in Wistar rats using a full-thickness excision wound healing model. CONCLUSION: The emulgels of mupirocin calcium NLCs appear to be effective in the treatment of contaminated wounds due to increased skin deposition and sustained release, thereby enhancing the wound healing potential of existing molecules.

Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned.

OBJECTIVE: To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm. DESIGN: Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data. SETTING: A tertiary referral center. PATIENTS: Patients undergoing excision of rectal endometriosis. INTERVENTION(S): Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach. MAIN OUTCOME MEASURE(S): Feasibility of the technique. RESULT(S): The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler's jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required. CONCLUSION(S): The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.

Topical Application of Virus-Derived Immunomodulating Proteins and Peptides to Promote Wound Healing in Mouse Models.

Immune modulators play critical roles in the progression of wounds to normal or conversely delayed healing, through the regulation of normal tissue regrowth, scarring, inflammation, and growth factor expression. Many immune modulator recombinants are under active preclinical study or in clinical trial to promote improved acute or chronic wound healing and to reduce scarring. Viruses have evolved highly efficient immune modulators for the evasion of host-defensive immune responses that target and kill invasive viruses. Recent studies have proven that some of these virus-derived immune modulators can be used to promote wound healing with significantly improved speed and reduced scarring in rodent models. Mouse full-thickness excisional wound model is one of the most commonly used animal models used to study wound healing for its similarity to humans in the healing phases and associated cellular and molecular mechanisms. This chapter introduces this mouse dermal wound healing model in detail for application in studying viral immune modulators as new treatments to promote wound healing. Details of hydrogel, protein construction, and topical application methods for these therapeutic proteins are provided in this chapter.

Disc Excision using Transanal Circular Stapler for Deep Endometriosis of the Rectum in 10 Steps.

OBJECTIVE: Deep endometriosis infiltrating the rectum may be managed by full-thickness disc excision, with the goal of preserving rectal function and avoiding low anterior rectal resection syndrome (Supplemental Appendix 1). Transanal staplers may be successfully used to remove rectal wall discs and concomitantly to perform rectal suture. The goal of this video article is to identify 10 steps that may render the procedure standardized and reproducible. DESIGN: Step-by-step video demonstration of the procedure. SETTING: A French tertiary referral center. INTERVENTIONS: The video presents disc excision of deep endometriosis infiltrating the rectum using a transanal circular stapler, following 10 steps: (1) nodule dissection and rectum releasing; (2) rectal shaving; (3) removal of fat tissue on the lateral rectal wall; (4) placement of a suture on the shaved area; (5) introduction of the closed transanal circular stapler; (6) stapler opening at the nodule's level; (7) knot performing; (8) stapler closing and firing; (9) stitches reinforcing the stapled line; and (10) performing a bubbles test. From 2009 to 2020, the author has performed this procedure in 205 patients: the mean disc diameter was 40 ± 8 mm; microscopic foci were found on the disc edges in 25.7%; and the rectal recurrence rate was 1.5%, whereas the leakage rate was 4.4%. The local institutional review board stated that approval was not required because the video describes a technique and does not report a clinical case. CONCLUSION: Disc excision using a transanal circular stapler following 10 steps is a standardized and reproducible procedure. The learning curve may be short because colorectal surgeons routinely employ the stapler to perform laparoscopic colorectal anastomosis.

Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases.

STUDY QUESTION: What are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed? SUMMARY ANSWER: In patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage. WHAT IS KNOWN ALREADY: Bowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management. STUDY DESIGN, SIZE, DURATION: A retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres. PARTICIPANTS/MATERIALS, SETTING, METHODS: One thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management. MAIN RESULTS AND THE ROLE OF CHANCE: Of 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom 23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision + segmental resection was 6.8 (1.9-23.8), 4.8 (1.4-16.9) and 11 (2.1-58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008). LIMITATIONS, REASONS FOR CAUTION: The main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon. WIDER IMPLICATIONS OF THE FINDINGS: Deep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures. STUDY FUNDING/COMPETING INTEREST(S): CIRENDO is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE Association. No financial support was received for this study. H.R. reports personal fees from ETHICON, Plasma Surgical, Olympus and Nordic Pharma outside the submitted work. The other authors declare no conflict of interests related to this topic.

Pluronic lecithin organogel of 5-aminosalicylic acid for wound healing.

5-Aminosalicylic acid (5-ASA) is an aminosalicylate anti-inflammatory drug, which is also known as mesalazine or mesalamine. Currently employed in treating inflammatory bowel disease, ulcerative colitis, inflamed anus or rectum, and maintain remission in Crohn's disease. Evidence from the researchers highlighted its significant re-epithelization in allergic asthma, aphthous, and gastric ulcerative conditions. The objective of the study was to formulate the pluronic lecithin organogel (PLO) containing 5-ASA and evaluate its wound-healing ability in a full thickness excision wound rat model. The data obtained from in silico docking studies revealed 5-ASA is having an affinity towards the transforming growth factor-beta (TGF-ß) specifically towards beta1. Among various formulations prepared (F1 to F8), F1, and F6 have shown a maximum in vitro drug release with optimum pH and viscosity. From MTT assay it was found that selected PLO formulations showed no toxicity and enhanced cell proliferation in HaCaT cell lines. In vivo wound-healing studies in albino Wistar rats has revealed that PLO accelerates wound closure and reepithelization to the statistically significant level on day 3 (p < .05) in comparison with untreated wounds. In conclusion, the overall results suggest that 5-ASA PLO gel is a potential therapeutic option for the treatments of wounds, however, further studies are highly warrened to determine the various mechanisms of 5-ASA in regulating the cell migration and reepithelization in wound healing to outspread its use in clinics.

Topical Digitoxigenin for Wound Healing: A Feasibility Study.

(1) Background: Cardiotonic steroids have been found to stimulate collagen synthesis and might be potential wound healing therapeutics. The objective of this study was to evaluate the feasibility of digitoxigenin and its topical formulation for wound healing; (2) Methods: In the in vitro study, the human dermal fibroblast cells were treated with digitoxigenin and collagen synthesis was assessed. In the in vivo study, digitoxigenin was applied to excisional full-thickness wounds in rats immediately after wounding and remained for three days, and wound open was evaluated over 10 days. A digitoxigenin formulation for topical administration was prepared, and the in vitro release and in vivo wound healing effect were investigated; (3) Results: The expression of procollagen in human dermal fibroblast was significantly increased with the exposure to 0.1 nM digitoxigenin. Topical application of digitoxigenin in olive oil or alginate solution for three days significantly decreased the wound open in rats. Similarly, topical administration of the developed digitoxigenin formulation for three days also significantly increased wound healing. No wound healing effects were observed at days 7 and 10 after wounding when digitoxigenin was not applied; and, (4) Conclusions: It was possible to deliver digitoxigenin using the developed formulation. However, the wound healing effect of digitoxigenin and its mechanisms need to be further investigated in future studies.

Transanal Endoscopic Microsurgery for Patients with Rare Rectal Tumors.

BACKGROUND: Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. Rare rectal tumors consist of several different types of malignant or benign tumors. Surgical management is considered to be the only curative option. The aim of this study is to investigate the role of TEM in the treatment of rare rectal tumors. MATERIALS AND METHODS: A total of 147 patients with rare rectal tumors underwent TEM in our center from April 2006 to May 2017. Clinical data were collected and a retrospective accurate database was constructed. Demographic characteristics, operative details, tumor details, complications, and follow-up data were analyzed. RESULTS: Seventy-eight patients were male. Mean tumor diameter was 1.2 ± 0.7 cm and mean distance from the anal verge was 6.6 ± 2.3 cm. Full-thickness and complete resection with negative margins was achieved in all patients. Complications occurred in 3 patients during surgery and in 20 patients after surgery. Histopathologic results were neuroendocrine tumors in 104 patients; gastrointestinal stromal tumors in 35; melanoma, lymphoma, and leiomyoma each in 2; lipoma, and squamous carcinoma each in 1. One hundred thirty-five patients were followed up for 49.3 ± 33.2 months. Two patients died, 1 had local recurrence and 1 had a rectovaginal fistula 1 month after surgery. No local recurrence or metastasis, or fecal incontinence was observed in the remaining patients. CONCLUSION: TEM is an optimal treatment option for selected rare rectal tumors. The complication rate is low and the therapeutic effect is satisfactory.

Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients.

OBJECTIVE: To assess the postoperative outcomes of patients with rectal endometriosis managed by disc excision using transanal staplers. DESIGN: Prospective study using data recorded in the CIRENDO database (NCT02294825). SETTING: University tertiary referral center. PATIENT(S): A total of 111 consecutive patients managed between June 2009 and June 2016. INTERVENTION(S): We performed rectal disc excision using two different transanal staplers: [1] the Contour Transtar stapler (the Rouen technique); and [2] the end to end anastomosis circular transanal stapler. MAIN OUTCOMES MEASURE(S): Pre- and postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. RESULT(S): The two staplers were used in 42 (37.8%) and 69 patients (62.2%), respectively. The largest diameter of specimens achieved was significantly higher using the Rouen technique (mean ± SD, 59 ± 11 mm vs. 36 ± 7 mm), which was used to remove nodules located lower in the rectum (5.5 ± 1.3 cm vs. 9.7 ± 2.5 cm) infiltrating more frequently the adjacent posterior vaginal wall (83.3% vs. 49.3%). Associated nodules involving sigmoid colon were managed by distinct procedures, either disc excision (2.7%) or segmental resection of sigmoid colon (9.9%). Postoperative values for the Gastrointestinal Quality of Life Index increased 1 and 3 years after the surgery, but improvement in constipation was not significant. The probability of pregnancy at 1 year after the arrest of medical treatment was 73.3% (95% confidence interval 54.9%-88.9%), with a majority of spontaneous conceptions. CONCLUSION(S): Disc excision using transanal staplers is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, allowing for good preservation of rectal function.

Significance of defect closure following transanal local full-thickness excision of rectal malignant tumors.

Transanal excision (TAE) for rectal tumors is increasingly applied and it is generally recommended that the defect following full-thickness excision should be closed. The aim of this study was to compare the complications and anal function following TAE between cases where the defect was closed and those where it was not. A total of 43 consecutive rectal malignant tumor patients eligible for TAE were investigated. Regarding anorectal function, incontinence was assessed using the Wexner score. The defect of the rectum was closed in 21 of the 43 patients. There were no significant differences between the two groups regarding gender, distance from the anal verge, tumor size, diagnosis and tumor site. There was a significantly higher number of postoperative complications of all grades and ≥Clavien-Dindo grade IIIa in the closure group (P=0.02 and 0.04, respectively). Regarding the Wexner score, there was no significant difference between the two groups (P=0.24). Compared with the closure group, the non-closure group had significantly fewer postoperative complications of all grades and ≥Clavien-Dindo grade IIIa. Moreover, there was no significant difference regarding the anorectal function between the two groups. Thus, suturing the rectal defect is not necessarily recommended following TAE.

Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions: A single centre experience.

AIM: To analyze the outcomes of transanal endoscopic microsurgery (TEM) in the treatment of rare rectal condition like mesenchymal tumors, condylomas, endometriosis and melanoma. METHODS: We retrospectively reviewed a twenty-three years database. Fifty-two patients were enrolled in this study. The lesions were considered suitable for TEM if they were within 20 cm from the anus. All of them underwent an accurate preoperative workup consisting in clinical examination, total colonoscopy with biopsies, endoscopic ultrasonography, and pelvic computerized tomography or pelvic magnetic resonance imaging. Operative time, intraoperative complications, rate of conversion, tumor size, postoperative morbidity, mortality, the length of hospital stay, local and distant recurrence were analyzed. RESULTS: Among the 1328 patients treated by TEM in our department, the 52 patients with rectal abnormalities other than adenoma or adenocarcinoma represented 4.4%. There were 30 males (57.7%) and 22 females (42.3%). Mean age was 55 years (median = 60, range = 24-78). This series included 14 (26.9%) gastrointestinal stromal tumors, 21 neuroendocrine tumors (40.4%), 1 ganglioneuroma (1.9%), 2 solitary ulcers in the rectum (3.8%), 6 cases of rectal endometriosis (11.5%), 6 cases of rectal condylomatosis (11.5%) and 2 rectal melanomas (3.8%). Mean lesion diameter was 2.7 cm (median: 4, range: 0.4-8). Mean distance from the anal verge was 9.5 cm (median: 10, range: 4-15). One patient operated for rectal melanoma developed distant metastases and died two years after the operation. We experienced 2 local recurrences (3.8%) with an overall survival equal to 97.6% (95%CI: 95%-99%) at the end of follow-up and a disease free survival of 98% (95%CI: 96%-99%). CONCLUSION: We could conclude that TEM is an important therapeutical option for rectal rare conditions.

Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review.

BACKGROUND: The last three decades have witnessed significant improvements in the diagnosis, staging and treatment of rectal cancer leading to a more tailored approach. One of the most clinically relevant advances in this field is represented by transanal endoscopic microsurgery (TEM). Several studies have investigated its role in the treatment of rectal cancer. However, evidence-based recommendations are limited. The aim of this report is to provide an evidence-based review of current indications, controversies and future perspectives of TEM in the management of rectal cancer. METHODS: A review of the literature has been performed in PubMed/Medline electronic databases and the Cochrane Library. Quality of evidence was evaluated according to the GRADE system. RESULTS: TEM allows to perform a more accurate en bloc full-thickness local excision of rectal tumors than transanal excision. TEM alone seems to provide similar oncologic results in selected T1sm1 N0 rectal cancers to those achieved by rectal resection and total mesorectal excision (TME), without impairing anorectal function. The oncologic outcomes of neoadjuvant therapy followed by TEM for selected T2 N0 rectal cancers are promising, but this approach is still under evaluation. A word of caution comes from the increased rate of suture dehiscence and rectal pain after TEM. TEM is a promising tool for the surgical treatment of locally advanced rectal cancer as a platform for transanal TME. CONCLUSIONS: Selected T1 rectal cancers with favorable features may be effectively treated with TEM without jeopardizing long-term oncologic outcomes. The lack of adequate lymphadenectomy represents the main concern of this approach for the treatment of rectal cancer. Several approaches are under evaluation to overcome this limitation.

Deep shaving and transanal disc excision in large endometriosis of mid and lower rectum: the Rouen technique.

BACKGROUND: Colorectal resection is performed in a majority of patients presenting with large endometriosis of mid and lower rectum; however, it may negatively and irreversibly impact postoperative rectal function. To avoid such unfavourable outcomes, we propose an original technique combining laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler. METHODS: The video presents the procedure performed in a 29-year-old nullipara referred with a large endometriotic nodule infiltrating the lower rectum on more than 30 mm length. The first step is laparoscopic and involves deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision of shaved area is performed, by placing traction parachute sutures in the middle and outside the shaved area. Their traction induces the prolapse of shaved area that is resected using a semicircular stapler. Insufflating the rectum with air checks the integrity of the staple line. RESULTS: Operative time was 210 min. Immediate postoperative outcomes were uneventful, and bowel movements were normal beginning with day 6. Our technique is suitable in large rectal nodules located up to 10 cm above the anus, infiltrating the rectum on up to 6 cm length, and these parameters are preoperatively assessed using MRI and computed tomography. To date, it was successfully carried out in 29 women with large deep endometriosis of the mid and lower rectum. Rectovaginal fistula was recorded in one patient (3.6 %) and transitory bladder dysfunction in seven patients (25 %). Digestive function assessment using standardized questionnaires revealed an overall improvement, without de novo anal continence troubles. Postoperative pregnancy rate was 78 % with a majority of patients having conceived spontaneously. CONCLUSIONS: Based on our experience, we believe that our conservative technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.

Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors.

AIM: To assess the efficacy of full-thickness excision using transanal endoscopic microsurgery (TEM) in the treatment of rectal neuroendocrine tumors. METHODS: We analyzed the data of all rectal neuroendocrine tumor patients who underwent local full-thickness excision using TEM between December 2006 and December 2014 at our department. Data collected included patient demographics, tumor characteristics, operative details, postoperative outcomes, pathologic findings, and follow-ups. RESULTS: Full-thickness excision using TEM was performed as a primary excision (n = 38) or as complete surgery after incomplete resection by endoscopic polypectomy (n = 21). The mean size of a primary tumor was 0.96 ± 0.21 cm, and the mean distance of the tumor from the anal verge was 8.4 ± 1.4 cm. The mean duration of the operation was 57.6 ± 13.7 min, and the mean blood loss was 13.5 ± 6.6 mL. No minor morbidities, transient fecal incontinence, or wound dehiscence was found. Histopathologically, all tumors showed typical histology without lymphatic or vessel infiltration, and both deep and lateral surgical margins were completely free of tumors. Among 21 cases of complete surgery after endoscopic polypectomy, 9 were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. No recurrence was noted during the median of 3 years' follow-up. CONCLUSION: Full-thickness excision using TEM could be a first surgical option for complete removal of upper small rectal neuroendocrine tumors.

Laparoscopic and transanal excision of large lower- and mid-rectal deep endometriotic nodules: the Rouen technique.

OBJECTIVE: To report an original technique of combined laparoscopic and transanal disc excision of lower- and mid-rectal deep endometriotic nodules. DESIGN: Video article introducing a new surgical technique. SETTING: University hospital. PATIENT(S): A 30-year-old nullipara with symptomatic deep endometriosis-large nodules involving the vagina and the lower rectum over 30 mm. INTERVENTION(S): An original technique of combined laparoscopic and transanal approaches, including deep rectal shaving using PlasmaJet, followed by transanal full thickness disc excision of the shaved area using the Contour Transtar stapler. MAIN OUTCOME MEASURE(S): The procedure is based on specific properties of PlasmaJet (the lack of lateral thermal spread making the dissection on contact of the rectal wall safe, the precise ablative property allowing for in situ ablation of rectal endometriosis implants) and those of the Contour Transtar stapler, which was originally developed to perform stapled transanal rectal resection of the internal rectal prolapse or rectocele. The steps of the Rouen technique and the role of the two devices are emphasized. Surgical technique reports in anonymous patients are exempted from ethical approval by the Institutional Review Board. The patient gave consent to use the video in the article. RESULT(S): The patient's functional outcome was uneventful, except for transitory incomplete bladder voiding. Since June 2009, we have successfully employed this technique in 15 patients with low rectal nodules, with only favorable digestive functional outcomes. CONCLUSION(S): Our technique is suitable for large nodules involving the lower and mid-rectum and avoids low colorectal resection, thus increasing the chance of favorable functional digestive outcomes.

New disc excision procedure for low and mid rectal endometriosis nodules using combined transanal and laparoscopic approach.

AIM: Colorectal resection in women with endometriosis involving the low and mid rectum may result in a poorer outcome than conservative procedures. In this technical note we present a new technique for transanal full thickness disc excision of endometriosis nodules involving the rectum. METHOD: The procedure is performed by combined laparoscopic and transanal routes. The former involves paring the area of the rectum infiltrated by the nodule, which is then made amenable to endoluminal removal using the Contour Transtar stapler to carry out a large disc excision. RESULTS: The technique can remove a specimen as large as 80 mm in diameter and can be applied to patients with infiltrating rectal endometrial nodules up to 10 cm from the anal margin and 50-60% of the rectal circumference. The procedure is probably less likely to lead to rectal stenosis and denervation than colorectal resection. CONCLUSION: This technique of transanal rectal disc excision using the Contour stapler is suitable in patients with infiltrating deep endometriosis nodules of the lower and mid rectum. It avoids a low rectal resection with its potential complications and unfavourable function.

Giant inflammatory linear verrucous epidermal nevus: successfully treated with full thickness excision and skin grafting.

Inflammatory linear verrucous epidermal nevus (ILVEN) is a pruritic, erythematous scaly epidermal nevus which follows a Blaschko's lines. Lichen striatus, linear Darier disease, linear porokeratosis, linear lichen planus, linear psoriasis, and the verrucous stage of incontinentia pigmenti may all have similar clinical presentations as the linear verrucous epidermal nevus. ILVEN can be distinguished from true nevoid psoriasis by pruritus and lack of response to antipsoriatic treatments. Various therapeutic modalities have been described, but no one therapy has been successful consistently. Though giant ILVEN is a relative contraindication to surgical excision, here we report a case showing effectiveness of full thickness excision and skin grafting for this condition.

Oculoplastic surgery.

Esthetic and functional surgery in the periocular region falls into the domain of oculoplastic surgeons, as well as plastic surgeons and otorhinolaryngologists with training in facial plastic surgery. This article provides a description of 8 common eyelid procedures that are routinely performed under local anesthesia, with or without mild intravenous sedation. Serious complications are rare. The rate of postoperative infection in the highly vascularized eyelid tissues is less than 1% in our experience.