[Endoscopic diagnosis, treatment, and follow-up of polyps of the lower gastrointestinal tract]. / Endoskopische Diagnostik, Therapie und Nachsorge von Polypen des unteren Gastrointestinaltrakts.

BACKGROUND: The endoscopic management of polyps of the lower gastrointestinal tract (l-GIT) has emerged in recent years as a result of numerous technological innovations. However, proven expertise and experience are essential. OBJECTIVES: Presentation of novel and standard techniques and best-practice recommendations for the characterization and resection of l­GIT polyps. METHODS: Recent specialist literature and current guidelines. RESULTS: High-definition endoscopy should be the standard when performing colonoscopy. The (virtual) chromoendoscopy can improve detection and characterization of polyps, but always requires special expertise and experience of the endoscopist in advanced endoscopic imaging. In this regard, computer-aided-diagnosis (CAD) systems have the potential to support endoscopists in the future. Pedunculated polyps should be removed with a hot snare. Small flat polyps can be resected by cold snare or large forceps. Large, non-pedunculated polyps should be treated in an interdisciplinary approach at a referral center with long-standing experience depending on its malignancy potential. After complete resection of small adenoma without high grade dysplasia, surveillance endoscopy is recommended after 5-10 years. Patients with large adenoma or high grade dysplasia should undergo endoscopy after 3 years and patients with multiple adenoma earlier than 3 years. After incomplete or piecemeal resection or insufficient bowel preparation, near-term endoscopy is recommended. CONCLUSIONS: Adequate characterization and treatment are essential for the appropriate management of l­GIT polyps.

Endoscopic full-thickness resection and its treatment alternatives in difficult-to-treat lesions of the lower gastrointestinal tract: a cost-effectiveness analysis.

OBJECTIVE: Endoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives. DESIGN: Real data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer. RESULTS: The cost per case was €2852.20 for the EFTR group, €1712 for the standard endoscopic resection (SER) group, €8895 for the surgical resection group and €5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was €3708.98 for EFTR, €3115.10 for SER, €8924.05 for surgical treatment and €7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was €5196.47 for SER, €26 533.13 for surgical resection and €67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar. CONCLUSION: EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.

Alvimopan Is Associated With a Reduction in Length of Stay and Hospital Costs for Patients Undergoing Radical Cystectomy.

OBJECTIVE: To evaluate the impact of alvimopan in patient undergoing radical cystectomy (RC) for bladder cancer. We hypothesize that alvimopan can decrease cost for RC by reducing length of stay (LOS). METHODS: We identified patients who underwent elective RC for bladder cancer from 2009 to 2015 in the Premier Healthcare Database, a nationwide, all-payer hospital-based database, and compared patients who received and did not receive alvimopan in the perioperative period. Hospitals that had no record of administering alvimopan for patients undergoing RC were excluded. The primary outcomes were LOS and the direct hospital costs. The secondary outcomes were 90-day readmission for ileus and major complications. RESULTS: After applying the inclusion criteria, the study cohort consisted of 1087 patients with 511 patients receiving perioperative alvimopan. Alvimopan was associated with a reduction in hospital costs by -$2709 (95% confidence interval: -$4507 to -$912, P = .003), decreased median LOS (7 vs 8 days, P < .001), and lower likelihood of readmission for ileus (adjusted odds ratio: 0.63, P = .041). While alvimopan use led to higher pharmacy costs, this was outweighed by lower room and board costs due to the reduced LOS. There was no significant difference between 2 groups regarding major complications. These results were robust across multiple adjusted regression models. CONCLUSION: Our data show that alvimopan is associated with a substantial cost-saving in patients undergoing RC, and suggest that routine use of alvimopan may be a potential cost-effective strategy to reduce the overall financial burden of bladder cancer.

How the Beneficial Effects of Alvimopan Differ With Surgical Approach for Radical Cystectomy.

OBJECTIVE: To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC). METHODS: This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis. RESULTS: Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P < .001), and longest time until ROBF (4 days, P < .001). On multivariable analysis, the interaction between surgical approach and alvimopan use was significant for the outcome of ROBF (estimate, 1.109; 95% confidence interval, 0.418-1.800; P = .002). In the RARC cohort, multivariable analysis showed no benefit of alvimopan with respect to ileus (P = .27), LOS (P = .09), or ROBF (P = .36). Regarding joint effects of robotic approach and alvimopan, RARC had no effect on gastrointestinal tract outcomes. CONCLUSION: We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Endoscopic full-thickness resection (EFTR) in the lower gastrointestinal tract.

BACKGROUND: Endoscopic full-thickness resection (EFTR) significantly expands the spectrum of endoscopic colorectal resection methods for lesions that show no lifting sign, submucosal lesions and mucosal carcinomas. The aim of our study was to evaluate the efficacy and safety of EFTR using a commercially available full thickness resection device (FTRD) by assessing the completeness of the full-thickness resection, the technical success, as well as complications in a cohort of patients from three referral centers in Germany. Another aim was to determine which patient subpopulations benefit most in clinical practice. METHODS: This retrospective multicenter study was conducted on consecutive patients who were admitted to three referral centers in Germany between November 2014 and December 2017. The EFTR was conducted according to the standard indications using the FTRD System (OVESCO, Tübingen, Germany). Data were obtained from prospectively maintained institutional databases. RESULTS: There were 70 patients, 42 males and 25 females with a mean age of 79.5 years (range 25-89 years) who had colonoscopy for EFTR. In three patients EFTR was not feasible because the lesions were too large. Of the remaining 67 patients, 52 had recurrent adenomas, 10 had high-grade intraepithelial neoplasia or mucosal carcinoma and five had a subepithelial lesion. Resection was technically successful in 65 patients (97.0%). Histologically complete resection (R0) was achieved in 59/65 patients (90.8%). The R0 resection rate was lower for lesions > 20 mm (86.5%) versus lesions ≤ 20 mm (92.9%). The total complication rate was 14.9%: there was one major complication (perforation of sigmoid colon), while all other complications were minor. CONCLUSIONS: EFTR yields excellent resection rates for benign recurrent adenomas with non-lifting sign, advanced histopathological findings or submucosal lesions when the procedure is performed in experienced hands and for the correct indication. Thus, surgery can be avoided in many cases. For all lesions the risk of R1 resection goes up with the size of the lesion and careful patient selection is mandatory.

International consensus statement regarding the use of animal models for research on anastomoses in the lower gastrointestinal tract.

PURPOSE: This project aimed to reach consensus on the most appropriate animal models and outcome measures in research on anastomoses in the lower gastrointestinal tract (GIT). The physiology of anastomotic healing remains an important research topic in gastrointestinal surgery. Recent results from experimental studies are limited with regard to comparability and clinical translation. METHODS: PubMed and EMBASE were searched for experimental studies investigating anastomotic healing in the lower GIT published between January 1, 2000 and December 31, 2014 to assess currently used models. All corresponding authors were invited for a Delphi-based analysis that consisted of two online survey rounds followed by a final online recommendation survey to reach consensus on the discussed topics. RESULTS: Two hundred seventy-seven original articles were retrieved and 167 articles were included in the systematic review. Mice, rats, rabbits, pigs, and dogs are currently being used as animal models, with a large variety in surgical techniques and outcome measures. Forty-four corresponding authors participated in the Delphi analysis. In the first two rounds, 39/44 and 35/39 participants completed the survey. In the final meeting, 35 experts reached consensus on 76/122 items in six categories. Mouse, rat, and pig are considered appropriate animal models; rabbit and dog should be abandoned in research regarding bowel anastomoses. ARRIVE guidelines should be followed more strictly. CONCLUSIONS: Consensus was reached on several recommendations for the use of animal models and outcome measurements in research on anastomoses of the lower GIT. Future research should take these suggestions into account to facilitate comparison and clinical translation of results.

Expression of P53, HER2 and Ki67 proteins in rats subjected to bladder augmentation with stomach, colon and ileum.

PURPOSE: To study the expression of HER2, p53 and Ki67 proteins in cystoplasties. METHODS: Sixty rats were distributed randomly into three groups of 20 animals. Bladder augmentation was held to increase with ileum (Group I), colon (Group II) and stomach (Group III). Tissue samples of neobladder was collected from each rat to its own control. The animals were sacrificed after 12 weeks. The neobladder was withdrawn for immunohistochemistry analysis of p53, HER2 and Ki67 expression. Wilcoxon and Mann-Whitney tests were used for statistical study. RESULTS: There were no significant changes in the expression of p53 and HER2 proteins. It was observed significant increase (p<0.0001) in Ki67 expression in all groups, when compared with their respective controls. When the study groups were compared with each other, there was increase of cell proliferation in the largest gastrocystoplasties in respect of ileocystoplasties (p=0.004) and colocystoplasties (p=0.003). CONCLUSION: We observed significant increase of cell proliferation characterized by Ki67 protein in the digestive tract of the ileocystoplasties, the colocystoplasties and the gastrocystoplasties and this increase was significantly greater in gastrocystoplasties.

Expression of P53, HER2 and Ki67 proteins in rats subjected to bladder augmentation with stomach, colon and ileum

PURPOSE: To study the expression of HER2, p53 and Ki67 proteins in cystoplasties. METHODS: Sixty rats were distributed randomly into three groups of 20 animals. Bladder augmentation was held to increase with ileum (Group I), colon (Group II) and stomach (Group III). Tissue samples of neobladder was collected from each rat to its own control. The animals were sacrificed after 12 weeks. The neobladder was withdrawn for immunohistochemitry analysis of p53, HER2 and Ki67 expression. Wilcoxon and Mann-Whitney tests were used for statistical study. RESULTS: There were no significant changes in the expression of p53 and HER2 proteins. It was observed significant increase (p<0.0001) in Ki67 expression in all groups, when compared with their respective controls. When the study groups were compared with each other, there was increase of cell proliferation in the largest gastrocystoplasties in respect of ileocystoplasties (p=0.004) and colocystoplasties (p=0.003). CONCLUSION: We observed significant increase of cell proliferation characterized by Ki67 protein in the digestive tract of the ileocystoplasties, the colocystoplasties and the gastrocystoplasties and this increase was significantly greater in gastrocystoplasties.

Lower Gastrointestinal Bleeding in Children.

This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.

Effect of a preoperative gabapentin on postoperative analgesia in patients with inflammatory bowel disease following major bowel surgery: a randomized, placebo-controlled trial.

BACKGROUND: Postoperative pain management for patients with inflammatory bowel disease (IBD) can be challenging. These patients have a high tolerance to pain medication, and relative contraindications to the use of epidural analgesia, limiting the pain management options. We evaluated the effect of a single preoperative gabapentin dose on opioid consumption for patients with IBD undergoing abdominal surgery. Secondary outcomes were postoperative pain scores, opioid-related side effects, and patient's length of hospital stay. METHODS: Following Research Ethics Board approval and informed written consent, patients were randomly allocated into 2 groups receiving either 600 mg of oral gabapentin or placebo 1 hour before the surgery. A blinded anesthesiologist recorded pain scores at rest and movement twice daily for 2 postoperative days. Also recorded were opioid consumption, time of return of bowel function, time to discharge, and opioid-related side effects on the opioid-related symptom distress scale (ORSDS). RESULTS: Seventy-two patients completed the study. The difference in opioid consumption (P = 0.4169) and pain scores measured at rest and movement on all 4 postoperative visits was not statistically significant. There was no significant difference between gabapentin and placebo on all the 11 symptoms reported on the ORSDS. There was a slight increase in length of hospital stay in the placebo group, but the return of bowel function was similar between the groups. CONCLUSIONS: This study examined the effect of a single preoperative administration of gabapentin in patients with IBD undergoing major bowel surgery. Our results suggest a single preoperative oral dose of gabapentin 600 mg does not reduce postoperative pain scores, opioid consumption, or opioid-related side effects.

Lower gastrointestinal bleeding.

This article examines causes of occult, moderate and severe lower gastrointestinal (GI) bleeding. The difference in the workup of stable vs unstable patients is stressed. Treatment options ranging from minimally invasive techniques to open surgery are explored.

The role of surgery in treatment of diverticular disease of lower gastrointestinal tract.

Diverticulosis of lower gastrointestinal tract is a common disease with potentially lethal complications. Recent studies demonstrated that the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriateness of surgery so the approach has to be more individualized. On the other hand, the complicated diverticular disease requires surgical treatment, often matter of urgency, and depends on localization and severity of the process. There is not sufficient evidence supporting the aggressive approach to treatment in younger patients. The available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.

Historia de la coloproctología: con especial referencia en Tucumán / History coloproctology: with particular reference in Tucumán

En este trabajo, en la primera parte se hacen algunas referencias sobre la Proctología o Coloproctología, como se la designa actualmente, a lo largo de la historia del hombre y a continuación tras una breve síntesis del desarrollo de la misma en Argentina realizamos un análisis del inicio y progreso de la especialidad en Tucumán destacando la figura del Dr. Julio U. Leites a quien consideramos el iniciador de la especialidad en Tucumán, objetivo principal de este trabajo. Finalizamos el mismo describiendo el posterior desarrollo de la coloproctología en la Sala 1 del Hospital Ángel C. Padilla.

In the first section of this report some facts about the history of Coloproctology are been referred. Afterwards through the story of mankind, a brief summary of the development in Argentine of the specialization and its competences is done. We have mentioned and analyze the beginning and progress of this branch of the surgery in Tucuman, remarking of Dr. Julio U. Leites figure, who is the very first surgeon in practice Proctology seriously and professionally. The last part of the article is to describe the beginning of Coloproctology at Angel C. Padilla Hospital.

Statin therapy and decreased incidence of positive Candida cultures among patients with type 2 diabetes mellitus undergoing gastrointestinal surgery.

OBJECTIVE: To assess whether statin therapy decreases the incidence of cultures positive for Candida species among high-risk hospitalized patients with type 2 diabetes mellitus (DM). PATIENTS AND METHODS: We performed a retrospective cohort study analyzing the records of all patients with type 2 DM who were admitted to Massachusetts General Hospital for lower gastrointestinal tract surgery between January 1, 2001, and May 1, 2008. We defined statin exposure as the filling of at least 1 prescription of statins during the 6 months before hospitalization or during the current hospital stay. The primary outcome was a culture positive for Candida species during hospitalization. Clinical information on a wide range of covariates was collected. Logistic regression analysis was used to adjust for possible confounders. RESULTS: Of the 1019 patients who were eligible for the study, 493 (48%) were receiving statins. A total of 139 patients (14%) had at least 1 culture positive for Candida species during hospitalization. An adjusted multivariate model based on a backward stepwise elimination procedure showed that statin therapy significantly decreased the incidence of cultures positive for Candida species (odds ratio, 0.60; 95% confidence interval [CI], 0.38-0.96; P=.03) with a statistically significant prolonged time to event compared with no statin therapy (adjusted hazard ratio, 0.62; 95% CI, 0.44-0.88; P=.01). The benefit of statins was more prominent in patients with type 2 DM who had greater comorbidities (Charlson Comorbidity Index ≥2) (adjusted odds ratio, 0.47; 95% CI, 0.27-0.79; P=.01). CONCLUSION: Among patients with type 2 DM who underwent gastrointestinal surgery, use of statins correlated with a decreased incidence of cultures positive for Candida species.

Anastomoses of the lower gastrointestinal tract.

Patients with gastrointestinal anastomoses are treated by physicians of multiple specialties, including gastroenterologists, radiologists and surgeons. This Review provides an overview of the surgical principles and techniques involved in the creation of lower intestinal anastomoses, including some of the mechanisms of healing. Anatomical configurations of small and large bowel anastomoses are illustrated. Stapled, hand-sewn, and sutureless anstomotic techniques are also discussed. Laparoscopy has revolutionized our approach to surgery of the gastrointestinal tract and we describe some of the current and future minimally invasive techniques for creating anastomoses. The article also highlights principles important in minimizing potential short-term and long-term complications such as anastomotic leaks and strictures. Common risk factors for dehiscence include poor nutrition, immunosuppression, microvascular disease, obesity and technical errors. An evidence-based review of perioperative and postoperative management of intestinal anastomoses is provided to help optimize patient care. The routine use of nasogastric tubes and mechanical bowel preparation has no documented benefits and could contribute to postoperative complications. Upcoming strategies that might prove useful to reinforce anastomoses are also reviewed.

Surgical exposure and anatomy of the female pelvis.

Female pelvic anatomy encompasses the reproductive, urologic, and gastrointestinal systems. Knowledge of the inherent relations between these organ systems, as well as the ability to develop pelvic spaces, will enable the surgeon to approach pelvic pathology confidently. This article highlights basic anatomy of the female pelvis and emphasizes points of caution during pelvic surgery, as well as reviews the essential principles of pelvic support.

Sutureless intestinal anastomosis with the biofragmentable anastomosis ring: experience of 632 anastomoses in a single institute.

PURPOSE: Uncertainty with the safety of the biofragmentable anastomosis ring makes surgeons hesitate in its widespread use in intestinal surgery. This study was designed to evaluate the validity of the biofragmentable anastomosis ring as a routine anastomotic device in enterocolic surgery. METHODS: The study analyzed the nine-year experience of 632 biofragmentable anastomosis ring anastomoses performed in 617 patients: 525 (83 percent) as elective procedures and 107 (17 percent) as emergency. Three classic types of anastomosis, end-to-end (n=354), end-to-side (n=263), and side-to-side (n=15), were performed with a standard technique. RESULTS: Anastomotic sites included ileocolic/ileorectal in 283 patients (45 percent), colorectal in 148 (23 percent), enteroenteric in 101 (16 percent), and colocolic in 100 patients (16 percent). Anastomotic leakage with clinical relevance was observed in five patients (0.8 percent): three elective cases, and two emergency (2 colorectal anastomoses and 1 ileorectal required diversions). Among 13 instances (2.1 percent) with postoperative intestinal obstruction, only 1 required relaparotomy for closed-loop obstruction. Seven patients (1.1 percent; 4 elective cases, and 3 emergency) died postoperatively; no deaths were directly related to the biofragmentable anastomosis ring technique. CONCLUSIONS: Our data suggest that the anastomosis using the biofragmentable anastomosis ring is a uniform and highly reliable technique even in high-risk emergency surgery. Along with its clinical validities, clinical application of the biofragmentable anastomosis ring in different types of anastomoses in enterocolic surgery is expected to be expanded with a high level of technical safety.

[Evaluation of clinical necessity of gastrointestinal decompression after excision and anastomosis of lower digestive tract].

OBJECTIVE: To evaluate the clinical necessity of postoperative gastrointestinal decompression after operation on lower digestive tract. METHODS: Three hundred and sixty-eight patients who required excision and anastomosis of lower digestive tract were randomly divided into two groups, with or without receiving gastrointestinal decompression after operation. Clinical therapeutic efficacy and complications were compared between two groups. RESULTS: The volume of gastrointestinal suction ranged from 10 ml to 520 ml each day after operation, and was less on the first day than those on the second and the third day after operation in decompression group. There was no significant difference in the average girth between two groups before and after operation. The average girths were shorter before operation than those after operation in two groups (P< 0.001). There was no significant difference in postoperative defecation and urination time between two groups (P > 0.05). The complication rate was significantly higher in decompression group than that in non-decompression group (28% vs. 8.2%, P< 0.001). The incidence of pharyngolaryngitis was up to 23.1% in decompression group. There was no difference in hospital stay between the two groups after operation. CONCLUSION: The recovery of patients who receive excision and anastomosis of lower digestive tract will benefit from non-gastrointestinal decompression.

Side-to-side isoperistaltic strictureplasty in the treatment of extensive Crohn's disease.

BACKGROUND: First performed in 1992, the side-to-side isoperistaltic strictureplasty (SSIS) is a bowel-sparing surgical option for Crohn's patients presenting with sequentially occurring stenoses over long intestinal segments (>15 cm). This investigation was designed to study the outcomes and patterns of recurrence after a SSIS. MATERIALS AND METHODS: Between 1992 and 2003, 30 patients underwent SSIS at the University of Chicago. Their data were gathered prospectively in an Institutional Review Board-approved database. RESULTS: A total of 31 SSISs were constructed in 30 patients. As an indication of the severity of disease in these patients, 25 of 30 (83%) required a concomitant bowel resection, and 13 (43%) underwent at least one additional strictureplasty. The average length of diseased bowel used to construct the SSIS was 51 cm. The average length of residual small bowel after performance of SSIS was 275 cm, and the SSIS represented an average 19% of the remaining small bowel that would have otherwise been sacrificed with resection. Three patients experienced perioperative complications (10%) and one died (3%). Seven patients (23%) required reoperation to treat recurrence of symptoms within the first 5 years. In four of these patients, recurrence was found at or near the previous SSIS. CONCLUSIONS: A side-to-side isoperistaltic strictureplasty (SSIS) is a safe and effective surgical option for sequentially occurring Crohn's strictures over long intestinal segments.