Exploring the Efficacy of the Paula Method of Muscle Exercises in Managing Low Anterior Resection Syndrome Using an Integrative Approach: A Preliminary Study.

Background: Low anterior resection syndrome (LARS) is a post-proctectomy consequence characterized by variable and unpredictable bowel function, including clustering, urgency, and incontinence, which significantly impacts the quality of life. Currently, there is no established gold-standard therapy for LARS. Primary Study Objective: This study aimed to evaluate the effectiveness of the Paula method of exercise as part of an integrative treatment approach for patients with LARS. Design: This preliminary study utilized a single-arm pretest-posttest design. Setting: The study was conducted at a tertiary care medical center. Participants: Five patients diagnosed with LARS completed the study. Intervention: Participants underwent twelve weeks of individualized Paula method exercise sessions. Two questionnaires were employed to assess the severity of LARS and quality of life. Primary Outcome Measures: (1) Low Anterior Resection Syndrome (LARS) Score; (2) Memorial Sloan Kettering Cancer Bowel Function Instrument (MSK-BFI); (3) Global Quality-of-Life (QOLS) Score . Results: All participants completing the 12-week Paula exercise regimen reported no difficulty in engaging with the exercises. Statistically significant improvements were observed in both the LARS score and MSK-BFI (P = .039 and P = .043, respectively, Wilcoxon Rank Sum test). While there were improvements in the global quality-of-life score and functional scales of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, these improvements did not reach statistical significance. Conclusions: This preliminary study suggests that patients with LARS can successfully complete a 12-week exercise program using the Paula method, resulting in improved LARS scores. However, further investigation through larger, multicenter, randomized controlled trials is necessary to establish the efficacy of these exercises as a treatment for LARS.

A patient tailored approach to the surgical treatment of hemorrhoids leads to equal satisfaction following hemorrhoidectomy, stapled hemorrhoidopexy or a combination of both.

PURPOSE: Up to 20% of patients suffering from symptomatic hemorrhoids will require surgery. Excisional hemorrhoidectomy (EH) and stapled hemorrhoidopexy (SH) are both standard and safe procedures. While SH has a short-term advantage of faster recovery and lower postoperative pain, its long-term efficacy is debatable. This study aims to compare the outcomes of EH, SH, and a combined procedure of both. METHODS: A retrospective study compared the outcomes of patients treated surgically for hemorrhoids over a 5-year period. Eligible patients were asked by phone to complete a questionnaire evaluating recurrent symptoms, fecal incontinence, satisfaction, and self-assessed improvement in quality of life (QOL). RESULTS: This study included 362 patients, of whom 215 underwent SH, 99 underwent EH, and 48 underwent a combined procedure. No statistically significant differences were found between groups regarding complications, symptoms recurrence, or fecal incontinence. Combined procedure patients had significantly higher self-assessed improvement in QOL (P=0.04). CONCLUSION: In patients with symptomatic hemorrhoids, a tailored approach to symptomatic hemorrhoids is associated with high satisfaction rates and self-assessed improvement in QOL.

Sutureless energy-based wound closure: a step in the quest for trocar site hernia prevention.

OBJECTIVE: Easy and safe methods of fascia closure are needed in order to reduce the risk for trocar site hernias without affecting procedure time significantly. Here we present a method for port site closure using heat induced collagen denaturation. MATERIAL AND METHODS: Controlled heat-induced collagen denaturation was applied to laparoscopic trocar sites in living porcine animal models. These were compared to control trocar sites which were left open. Port sites were evaluated visually at days 14 and 28 after the procedure, and both visually and pathologically at post-procedural day 42. RESULTS: A total of 12 port sites were evaluated in three pigs. No incisional hernias were noted at any of the trocar sites in both groups. Histological evaluation revealed that one of the six control ports appeared to have a complete transfascial defect, whereas none of the study group trocars showed this finding. Furthermore, the study port sites showed a more robust scarring pattern. CONCLUSIONS: Heat-induced collagen denaturation in this preliminary study was found to be safe and allowed better scarring of the healing port sites. We believe that this technology may offer a safe and efficient closure of laparoscopic trocar sites. More studies are needed to further evaluate the true effectiveness of this technology.

Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease.

AIM: The aim of this work was to compare the results of elective minimally invasive surgery between patients with complicated sigmoid diverticulitis and those with uncomplicated disease. METHOD: An institutional review board-approved database was searched for all consecutive patients who underwent elective minimally invasive surgery, including laparoscopic, hand-assisted and robotic sigmoidectomy, for diverticulitis between 2010 and 2017; they were classified according to the modified Hinchey classification as having complicated (abscess, fistula, stricture, obstruction, bleeding or previous perforation) versus uncomplicated disease. Data recorded included baseline demographics, indications for surgery, operative details and complications. RESULTS: Three hundred and twenty-five patients underwent elective sigmoidectomy for complicated (n = 105) and uncomplicated (n = 220) diverticulitis. Surgical indications for complicated disease were abscess (n = 74), stricture (n = 14), fistula (n = 28) and bleeding (n = 7). The two groups were statistically comparable for age, gender, body mass index and American Society of Anesthesiologists score. Patients with complicated disease had higher rates of concomitant loop ileostomy creation (9.5% vs. 0.9%, p < 0.001) and synchronous resections (9.5% vs. 2.7%, p = 0.01), higher volumes of blood loss (177 ± 140 vs. 125 ± 92 ml, p < 0.001), longer length of stay (5.6 ± 3 vs. 4.8 ± 2 days, p = 0.04) and longer operating time (218.2 ± 59 vs. 185.8 ± 63 min, p < 0.001). There were no significant differences in anastomotic leakage (3% vs. 1%, p = 0.3), conversion to laparotomy (4.8% vs. 2.3%, p = 0.3) or overall complications (36% vs. 25.9%, p = 0.06) for complicated versus uncomplicated disease, respectively. CONCLUSION: Minimally invasive surgery for complicated diverticulitis resulted in higher rates of construction of proximal ileostomy and synchronous resections and longer operating times and length of hospital stay. Otherwise, it has outcomes that are not significantly different from the results recorded in patients with uncomplicated disease.

Changes in abdominal wall thickness during laparoscopy: implications for the use of magnetic assisted surgery.

Introduction: Recently, magnetic solutions have been proposed to minimize surgical invasiveness. These are comprised of deployable instruments containing magnets which are inserted into the abdominal cavity through a single access point. The manipulation of the internal elements occurs via magnets held on the external surface of the abdominal wall. This technology relies on the magnetic force between the magnets, which is inversely related to the abdominal wall thickness (AWT). The aim of this study was to establish the expected change in AWT from before and after initiation of pneumoperitoneum. Material and methods: Patients scheduled for laparoscopic procedures were assessed by ultrasound for AWT immediately before and during laparoscopy. Change of AWT during laparoscopy was calculated. Statistical analysis was performed using Student's t-test. Results: Thirty-two patients undergoing various laparoscopic procedures were included. Twenty patients were male (62.5%) and ten were morbidly obese (31%). Mean age was 51 years (range 18-76) and average BMI was 28.1 kg/m2 (range 19.0-41.0). AWT decreased on average by 15.6% once pneumoperitoneum was initiated in both obese and non-obese patients (p = .01). Conclusion: Our data suggest that following preoperative assessment of AWT with abdominal wall ultrasound, more patients than expected might be candidates for the use of trans-abdominal magnetic devices.

Outcome of bariatric surgery in patients with type 1 diabetes mellitus: our experience and review of the literature.

BACKGROUND: The beneficial effect of bariatric surgery (BS) in type 2 diabetes mellitus patients is well established. Conversely, little is known about the efficacy of BS in type 1 diabetes mellitus (T1DM) patients, despite the increasing prevalence of obesity in this population. METHODS: A retrospective review was carried out on a prospectively collected bariatric surgery registry of all patients undergoing BS at two university hospitals between 2010 and 2015. Patients with T1DM were identified, and detailed chart reviews were obtained. RESULTS: In this time period, we operated on thirteen patients with T1DM. Eight were female (61.5 %). Median age at time of surgery was 38 ± 8.3 (range 28-53) years. The procedures performed were laparoscopic sleeve gastrectomy (n = 10) and laparoscopic Roux-en-Y gastric bypass (n = 3). On median postoperative follow-up of 24 (range 2.5-51) months, mean body mass index significantly decreased from 39.9 ± 4.1 to 30.1 ± 3.9 kg/m2 (P < 0.0001) and insulin requirements were significantly reduced from 83.7 ± 40.4 to 45.7 ± 33.1 U/day (P < 0.01). However, there was no significant change in glycemic control assessed by HbA1C (P = 0.2). During the first months following surgery, three patients (21.4 %) experienced diabetic ketoacidosis, and four patients (28.6 %) reported more frequent episodes of hypoglycemia. CONCLUSIONS: Bariatric surgery in morbidly obese T1DM patients is an effective method for weight loss, leading to a remarkable improvement in insulin requirements. Larger prospective studies are still needed to confirm these findings, assess long-term effects of BS and better delineate its risk-to-benefit ratio in this growing population of morbidly obese patients with T1DM.

Reusable single-port access device shortens operative time and reduces operative costs.

BACKGROUND: In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. METHODS: We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. RESULTS: SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. CONCLUSION: Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

[Single incision laparoscopic combined cholecystectomy, bilateral salpingo-oophorectomy and omentectomy].

Single Incision Laparoscopic Surgery (SILS) is gaining popularity as a modality in surgery which reduces the number and size of skin incisions. General surgeons and urologists were the first to implement this technique, however, recently gynecologists have also started performing SILS procedures. We present the case of a 70 year old female who underwent a combined SILS procedure which included cholecystectomy, bilateral oophorectomy and omentectomy. The procedure lasted 100 minutes and the patient was discharged home the day after the operation. No operative or post-operative complications were noted. In this case report we present the technical details and demonstrate the collaboration between different disciplines which enables performing this complex and demanding procedure.

Incidence and Risk Factors for Low Anterior Resection Syndrome following Trans-Anal Total Mesorectal Excision.

BACKGROUND: Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME. METHODS: A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated. RESULTS: Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (p = 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. CONCLUSION: LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.

Endovascular management of blunt renal artery trauma.

BACKGROUND: Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported. OBJECTIVES: To present our experience with endovascular management of blunt renal artery injury, and review the literature. METHODS: We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications. RESULTS: Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered. CONCLUSIONS: Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.

Comparing laparoscopic mesh fixation strength between articulated and non-articulated tack devices.

AIM: The iMESH Tacker™ (IMT) device is a device which simplifies laproscopic hernia repair by enabling an articulation of the device tip. The study compares the strength of mesh fixation between the IMT and another commercial tack (ACT) device - Absorbatack™ (Covidien, Corp, Mansfield, MA, USA). MATERIAL AND METHODS: Strips of mesh were installed on the abodminal wall of three pigs. Half of the meshes were fixated by IMT and half by ACT. Euthanasia was done immediately to the first pig, after14 days to the second and after 27 days to the third pig. The mesh strips were pulled while fixation force was measured. Statistical analysis was done using the two tailed t-test. All mesh strips were found to be fixated. Through detachment force test, the average force in the first pig was 17.1N ± 1.9 and 16.5N ± 8.3 (IMT and ACT respectively, n/s). The average force in the second pig was 18.8N ± 7.3 and 8.4N ± 4.1 (IMT and ACT respectively, p < 0.05). The average force in the third pig was 16.3N ± 5.3 and 10.9N ± 5.9 (IMT and ACT respectively, p < 0.05). CONCLUSION: The use of IMT is both feasible and easy to learn. The study showed that IMT creates average fixation force which is higher than ACT.

Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application.

BACKGROUND: Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. METHODS: The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. RESULTS: The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. CONCLUSION: The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.

Laparoscopic partial nephrectomy using a flexible CO2 laser fiber.

BACKGROUND AND OBJECTIVES: Laparoscopic partial nephrectomy (LPN) is a challenging surgery that requires precise tissue cutting and meticulous hemostasis under warm ischemia conditions. In this study, we tested the feasibility of performing LPN using CO2 laser energy transmitted through a specialized flexible mirror optical fiber. METHODS: General anesthesia and pneumoperitoneum were induced in 7 farm pigs. Various portions of a kidney, either a pole or a midportion of the kidney, were removed using a novel flexible fiber to transmit CO2 laser energy set at a power of 45W and energy per pulse of 100mJ. The collecting system was approximated with a suture or 2, but no hemostatic measures were taken besides applying a few pulses of the laser to bleeding points. The pigs were sacrificed 3 wk later. RESULTS: Average renal mass removed was 18% of the total kidney weight. All pigs tolerated surgery well. Sharp renal cutting was accomplished in a single continuous incision, with minimal tissue charring and minimal blood loss (<10cc) in all animals. Necropsy revealed no peritoneal or retroperitoneal abnormalities. Histologic examination of the cut surface showed a thin sector of up to 100 m of coagulation necrosis. CONCLUSIONS: We report on the first LPN done using a CO2 laser transmitted through a flexible fiber in an animal model. This novel application of the CO2 laser produced excellent parenchymal incision and hemostasis along with minimal damage to adjacent renal tissue, thus, potentially shortening ischemia time and kidney function loss. Further studies comparing this laser to standard technique are necessary to verify its usefulness for partial nephrectomy.

Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

A mouse model for sleeve gastrectomy: applications for diabetes research.

INTRODUCTION: Discovery of enhanced glucose tolerance following bariatric surgery has sparked renewed interest in the investigation of unchartered underlying pathways of glucose homeostasis. Delineation of this pathway may ultimately be the first step in the creation of a novel therapy for type II diabetes. Nevertheless, the technical complexity and formidable nature of these surgeries coupled with the fragile nature of small rodents has made the creation of a mouse model to study these effects incredibly challenging. We have created a simplified sleeve gastrectomy mouse model to study the effects of bariatric surgery on glucose tolerance and beta cell proliferation. METHODS: Nineteen mice were randomized to undergo either sleeve gastrectomy (SG) (9) or sham operation (SH) (10). Weight and serum glucose were measured three times weekly and serum insulin measurements and pancreatic harvest were performed at the time of sacrifice. Five mice from each group were sacrificed after one week and the remainder sacrificed after one month. RESULTS: Survival of mice was 100% for both groups. The SG group demonstrated an initial drop in weight and serum glucose as compared to SH, which normalized by one month following surgery. Serum insulin levels and rate of beta cell proliferation were similar in both groups after one week and one month. CONCLUSION: The simplified sleeve gastrectomy is a technically straightforward, low-mortality technique for creating a bariatric mouse model which most faithfully replicates bariatric surgery performed in humans. This model can be a valuable tool to investigate the glucose tolerance and beta cell effects of bariatric surgery.

Assessing the development status of intraoperative fluorescence imaging for perfusion assessments, using the IDEAL framework.

OBJECTIVES: Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: assessing tissue perfusion; identifying/localizing cancer; mapping lymphatic systems; and visualizing anatomy. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging for perfusion assessments using the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework, which was designed for describing the stages of innovation in surgery and other interventional procedures. DESIGN: Narrative literature review with analysis of IDEAL stage of each field of study. SETTING: All publications on intraoperative fluorescence imaging for perfusion assessments reported in PubMed through 2019 were identified for six surgical procedures: coronary artery bypass grafting (CABG), upper gastrointestinal (GI) surgery, colorectal surgery, solid organ transplantation, reconstructive surgery, and cerebral aneurysm surgery. MAIN OUTCOME MEASURES: The IDEAL stage of research evidence was determined for each specialty field using a previously described approach. RESULTS: 196 articles (15 003 cases) were selected for analysis. Current status of research evidence was determined to be IDEAL Stage 2a for upper GI and transplantation surgery, IDEAL 2b for CABG, colorectal and cerebral aneurysm surgery, and IDEAL Stage 3 for reconstructive surgery. Using the technique resulted in a high (up to 50%) rate of revisions among surgical procedures, but its efficacy improving postoperative outcomes has not yet been demonstrated by randomized controlled trials in any discipline. Only one possible adverse reaction to intravenous indocyanine green was reported. CONCLUSIONS: Using fluorescence imaging intraoperatively to assess perfusion is feasible and appears useful for surgical decision making across a range of disciplines. Identifying the IDEAL stage of current research knowledge aids in planning further studies to establish the potential for patient benefit.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.

Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury.

BACKGROUND: The recent growth in the volume of civilian blast trauma caused by terrorist bombings warrants special attention to the specific pattern of injury associated with such attacks. OBJECTIVE: To characterize the abdominal injuries inflicted by terrorist-related explosions and to compare the pattern of injury with civilian, penetrating and blunt, abdominal trauma. METHODS: Retrospective analysis of prospectively collected data from 181 patients with abdominal trauma requiring laparotomy, who were admitted to the Hadassah Hospital, Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into 3 groups according to mechanism of injury: terror-related blast injury (n = 21), gunshot wounds (GSW) (n = 73) and blunt trauma (n = 87). RESULTS: Median injury severity score in the blast group was significantly higher compared with GSW and blunt groups (34, 18, and 29, respectively, P < 0.0001). Injury to multiple body regions (> or = 3) occurred in 85.7% of blast group, 28.8% of GSW group, and 59.7% of blunt group (P < 0.001). The pattern of intra-abdominal injury was different between the groups. Bowel injury was found in 71.4% of blast victims, 64.4% of GSW, and 25.3% of blunt group (P < 0.001). Parenchymal injury was found in one third of patients in blast and GSW groups versus 60.9% of patients in blunt group (P = 0.001). Penetrating shrapnel was the cause of bowel injury in all but 1 patient in the blast group (94.4%). CONCLUSIONS: Terrorist attacks generate more severe injuries to more body regions than other types of trauma. Abdominal injury inflicted by terrorist bombings causes a unique pattern of wounds, mainly injury to hollow organs. Shrapnel is the leading cause of abdominal injury following terrorist bombings.

Management of rectovaginal fistulas and patient outcome.

INTRODUCTION: Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.

Re-appraisal and consideration of minimally invasive surgery in colorectal cancer.

Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.