Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results.

BACKGROUND: Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results. METHODS: Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated. RESULTS: Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured. CONCLUSION: The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

Aggressive Surgical Approach for Treatment of Primary and Recurrent Retroperitoneal Soft Tissue Sarcoma.

To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25-79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; P = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; P = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; P = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.

The Intact® breast lesion excision system as a therapeutic device for selected benign breast lesions.

The aim of this paper is to evaluate our Unit's initial experience using the Intact breast lesion excision system as a therapeutic excision option for benign or borderline breast lesions, which otherwise would entail open operative excision. The study includes the first 111 patients who underwent therapeutic excision with the intact radiofrequency system between December 2012 and May 2016 performed at the Meirav Center for Breast Health, at the Chaim Sheba Medical Center, Ramat Gan Israel. The indications for the procedure included those patients who have benign, or atypical high risk lesions following a previous core needle biospy (CNB) who would have normally undergone conventional excision biopsy. After reviewing each case separately, we found that the use of the BLES system as a treatment device permitted the avoidance of operations that would have been otherwise indicated, in 98 cases of the total 111 in the cohort (88.3%). Thirteen cases eventually had to undergo surgical excision. In eight cases pathology was upgraded from the initial CNB to invasive or noninvasive carcinoma. Although the INTACT sysytem is most commonly used as an alternative biopsy technique for its diagnostic capabilities, this study assessed its clinical role as a definitive therapeutic excisional modality in selected cases of benign breast disease. It proved valuable in the majority of cases with avoidance of surgery where it was traditionally indicated, (98/111, 88.3%) and as definitive fibroadenoma management in a further 28 patients.

Percutaneous cholecystostomy in the management of high-risk patients presenting with acute cholecystitis: Timing and outcome at a single institution.

BACKGROUND: Cholecystectomy is the standard of care in acute cholecystitis (AC). Percutaneous cholecystostomy (PC) is an effective alternative for high-risk surgical cases. METHODS: A retrospective analysis is presented of AC patients treated with PC drainage at a single tertiary institution over a 21 month period, assessing outcome and complications. RESULTS: Of 119 patients, 103 had clinical improvement after PC insertion. There were 7 peri-procedural deaths (5.9%), all in elderly high-risk cases. Overall, 56/103 cases (54%) were definitively managed with PC drainage with 41 patients (40%) undergoing an elective cholecystectomy (75% performed laparoscopically). The timing of PC insertion did not affect AC resolution or drain-related complications, although more patients underwent an elective cholecystectomy if PC placement was delayed (>24 h after admission). CONCLUSIONS: In AC, drainage by a PC catheter is a safe and effective procedure. It may be used either as a bridge to elective cholecystectomy or in selected cases as definitive therapy.

Changing paradigms in the management of diverticulitis.

The management of diverticular disease has evolved in the last few decades from a structured therapeutic approach including operative management in almost all cases to a variety of medical and surgical approaches leading to a more individualized strategy. There is an ongoing debate among surgeons about the surgical management of diverticular disease, questioning not only the surgical procedure of choice, but also about who should be operated and the timing of surgery, both in complicated and uncomplicated diverticular disease. This article reviews the current treatment of diverticulitis, with a focus on the indications and methods of surgery in both the emergency and elective settings. Further investigation with good clinical data is needed for the establishment of clear guidelines.

Optimizing treatment of hepatic metastases from colorectal cancer: Resection or resection plus ablation?

The present study determines the oncologic outcome of the combined resection and ablation strategy for colorectal liver metastases (CRLM). Between January 1994 and December 2014, 360 patients underwent surgery for CRLM. There were 280 patients who underwent hepatic resection only (group 1) and 80 hepatic resection plus ablation (group 2). group 2 patients had a higher incidence of multiple metastases than group 1 cases (100% in group 2 vs. 28.2% in group 1; P<0.001) and bilobar involvement (76.5% in group 2 vs. 12.9% in group 1; P<0.001). Perioperative mortality was nil in either group with a higher postoperative complication rate amongst group 1 vs. group 2 cases (18 vs. 0, respectively). The median follow-up was 90 months (range, 1-180) with a 5-year overall survival for group 1 and group 2 of 49 and 80%, respectively (P=0.193). The median disease-free survival for patients with R0 resection was 50, 43 and 34% at 1, 2 and 3 years, respectively, and remained steadily higher (at 50%) in those patients treated with resection combined with ablation up to 5 years (P=0.069). The only intraoperative ablation failure was for a large lesion (≥5 cm). Our data support the use of intraoperative ablation when complete hepatic resection cannot be achieved.

The Charlson Comorbidity Index (CCI) as a Mortality Predictor after Surgery in Elderly Patients.

The increasing range of surgery in elderly patients reflects the changing demography where in the next 10 years one quarter of the population will be 65 years of age or older. There is presently no consensus concerning the optimal predictive markers for postoperative morbidity and mortality after surgery in older patients with an appreciation that physical frailty is more important than chronological age. In this retrospective analysis, we have compared the impact of age and the calculated preoperative Charlson Comorbidity Index (CCI) on early (30-day) and late (one-year) mortality in a group of patients >75 years of age dividing them into an "older old" cohort (75-84 years of age, Group A) and an "oldest old" group (≥85 years of age, Group B). Increased age was associated with a higher death rate after emergency surgery, with late deaths after elective surgery exceeding those after emergency operations. A higher mean CCI was noted in both age groups in early nonsurvivors after both elective and emergency surgery with a more significant effect of the preoperative CCI than chronological age for the prediction of late postoperative death for both groups after elective and emergency operations. Although the CCI was not designed to predict perioperative mortality in surgical cohorts, it correlates with a greater risk than age for perioperative death in the elderly.

A novel porcine model for chemically inducible Crohn's-like reaction.

BACKGROUND: New animal models provide insights into the pathogenesis of different types of inflammatory bowel disease as well as novel pathways for new therapeutic options. However, the scarcity of large animal models hinders the research and development of new surgical procedures and technological devices in inflammatory bowel disease surgery. Common small animal inducible models involve chemical agents that result in the development of acute intestinal inflammation. OBJECTIVES: To assess a novel method for the induction of Crohn's-like colitis using intramural injection of sclerosants in a porcine model. METHODS: Seven domestic pigs underwent several experimental protocols to assess the efficacy of intramural colonic injections of two different compounds (lauromacrogol, and phenol in almond oil).Twenty-five different large bowel segments were treated with intramural injections of the compounds. The animals were followed for 6 weeks, and treated colonic segments were resected for histopathological examination. RESULTS: Intramural injection of lauromacrogol resulted in non-specific, mild reactive foreign body changes only. Injection of various dosages of 5% phenol in almond oil caused a range of histopathological changes varying from focal fibrosis to Crohn's-like reactions com rising acute and chronic infiltrates, mucosal ulceration and focal necrosis with enteric and lymphoid non-caseating granulomas. CONCLUSIONS: Intramural colonic phenol in almond oil injection in pigs induces inflammatory reactions that histologically resemble Crohn's disease in humans.

A case series of congenital hepatic hilar cyst: recommendations for diagnosis and management.

BACKGROUND: Congenital hepatic hilar cysts are rare. Some are simple and do not require intervention, but some biliary cystic malformations impose the risk of morbidity and mortality. OBJECTIVES: To assess a series of five patients presenting with congenital hepatic hilar cysts. METHODS: We retrospectively reviewed all cases presenting to our pediatric surgical service between January 2010 and December 2012 and found to have a congenital hepatic hilar cyst. Data regarding clinical, radiological, operative and pathological features were analyzed. RESULTS: Five children with congenital cyst of the hepatic hilum were identified; four of them were diagnosed prenatally. Four children had undergone surgical intervention: one with intrahepatic choledochal cyst, one with epidermoid cyst, and two with biliary atresia and an associated cyst of the common bile duct. In another case of choledochal cyst the treatment was conservative. All children except one had a good prognosis; one child with biliary atresia required liver transplantation. CONCLUSIONS: The differential diagnosis of congenital hepatic hilar cyst includes a broad spectrum of pathologies. It is essential to diagnose biliary atresia as early as possible. Signs such as smaller cysts in association with a hypoplastic gallbladder and direct hyperbilirubinemia may be suggestive of biliary atresia.

Early experience with laparoscopic lavage in acute complicated diverticulitis.

BACKGROUND: Contemporary surgical management of complicated diverticulitis is controversial. Traditionally, the gold standard has been resection and colostomy, but recently peritoneal lavage and drainage without resection in cases of purulent peritonitis have been suggested. This study aims to review our initial experience with laparoscopic peritoneal lavage for complicated diverticulitis. METHODS: Retrospective review of all patients who underwent emergent peritoneal lavage and drainage for acute complicated diverticulitis. RESULTS: Five-hundred-thirty-eight patients admitted for acute diverticulitis between 2007 and 2012 were recorded in the database. Thirty seven underwent emergent surgery of which 10 had peritoneal lavage and drainage without colonic resection for complicated diverticulitis causing peritonitis. Peritoneal lavage and drainage resulted in the resolution of acute symptoms in all cases. In long-term follow-up, 3 (30%) patients required elective resection owing to symptomatic disease, two of these due to recurrent diverticulitis, and one owing to complicated fistula following the procedure. CONCLUSION: Peritoneal lavage is a feasible option for complicated diverticulitis with purulent non-fecal peritonitis, but a significant portion of the patients may require elective resection. Comparative studies with emergent resection are needed to determine the role of peritoneal lavage in complicated diverticulitis.

Magnetic resonance imaging (MRI) evaluation of residual breast tissue following mastectomy and reconstruction with silicone implants.

PURPOSE: We present our use of magnetic resonance (MR) measurement to determine the amount of residual breast tissue (RBT) following total mastectomy with reconstruction. METHODS: Breast MR images of 45 women who underwent surgery between January and November 2011 were reviewed. The cohort included therapeutic and prophylactic mastectomies. RBT was evaluated at four points with a digital caliper assessing T2-weighted and T1-weighted images. RESULTS: Patients undergoing mastectomy for carcinoma tended to have less RBT than in prophylactic surgery. Greater age and recent surgery both correlated with larger RBT. CONCLUSIONS: Variable thickness of RBT is demonstrable following mastectomy and implant reconstruction using MR imaging.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal and appendiceal origin].

BACKGROUND: We report our initial experience combining cytoreductive surgery (CRS) plus intraperitoneal chemotherapy with hyperthermia (HIPEC) in a selected group of patients presenting with disseminated peritoneal carcinomatosis (PC) of colorectaL or appendiceaL origin at a single tertiary referral institution. METHODS: The study included patients who underwent CRS with HIPEC at the Sheba Medical Center between April 2009 and December 2011. The HIPEC technique was administered with the open Coliseum technique reaching a steady state of mitomycin-C delivery at 410 C for perfusion duration of 90 minutes. RESULTS: AnaLysis included 45 patients (18 males) incorporating 42 cases of primary colorectal cancer (CRC) or appendiceal cancer and 3 cases of pseudomyxoma peritonei. Thirty-seven patients (82%) underwent CC-0 resections with a median overall hospital stay of 8 days (range 5-43). There was one perioperative death at 90 days. The perioperative complication rate was 31.1%. The median follow-up was 12 months (range 2-36) during which 13 patients died. Among the CRC and appendiceal cancer group the median overall survival was 20.2 months and the median progression free survival was 16.4 months (Kaplan-Meier analysis). During follow-up, 23 patients experienced disease progression. CONCLUSION: The selective use of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis from colorectal or appendiceal origin is safe with acceptable morbidity and low mortality.

Freehand elastography for determination of breast cancer size: comparison with B-mode sonography and histopathologic measurement.

OBJECTIVES: Elastography assesses the strain of soft tissues and is used to enhance diagnostic accuracy in evaluating breast tumors, but minimal data exist on its ability to accurately assess tumor size. This study was performed to assess the preoperative accuracy of measuring the size of biopsyproven breast cancer lesions with elastography and conventional B-mode sonography compared with the reference standard size measured by histopathologic examination. METHODS: Elastography and conventional B-mode sonography were performed on 69 women with histologically proven breast cancer, and tumor sizes on both modalities were recorded. These measurements were compared with the final pathologic size, which was used as the reference standard. The sizes and differences between sonographic, elastographic, and pathologic measurements were statistically tested, and an analysis of equivalence to the reference standard was performed using Bland-Altman plots. RESULTS: There was a significant difference between sizes on elastography and pathologic examination, with elastography overestimating the tumor size (P = .0187). Sonography slightly underestimated the tumor size, but this finding was not significant (P = .36). Bland-Altman plots confirmed that sonography but not elastography was an acceptable standard compared with the pathologic size. CONCLUSIONS: Breast elastography but not B-mode sonography overestimates the size of breast tumors compared with the final pathologic size.

The antegrade continence enema procedure and total anorectal reconstruction.

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be 'dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations.

BACKGROUND: Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury. METHODS: Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal. RESULTS: Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis. CONCLUSIONS: In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.

Selective utilization of pre-operative endoscopic ultrasound to exclude choledocholithiasis prior to laparoscopic cholecystectomy: a retrospective study.

BACKGROUND/AIMS: The objective of this study was to define the clinical, biochemical and ultrasonographic criteria correlating with a likelihood of a positive preoperative endoscopic ultrasound (EUS) in patients presenting with acute gallstone-related pancreatobiliary disease. METHODOLOGY: All patients who underwent EUS prior to elective laparoscopic cholecystectomy were analyzed at the Gastroenterology Unit, Kaplan Medical Center, following acute admission with cholecystitis, cholelithiasis, cholangitis, acute pancreatitis and obstructive jaundice. RESULTS: One hundred and seventy four patients met the inclusion criteria. EUS showed choledocholithiasis in 37 (21.3%) with 35/37 undergoing a preoperative ERCP (24/35 cases - 64.9% positive yield). Twenty seven of the positive EUS studies (73%) were performed during the acute illness, with 50 of the 137 negative studies (36.4%) performed during the acute phase of the illness (p=0.0001). On multivariate analysis, a positive EUS was more commonly found during the acute phase of the illness [OR: 3.445; 95% CI: 1.48-8.008, p=0.004] or if there was transient jaundice [OR: 1.167; 95% CI: 1.002-1.36, p=0.047]. CONCLUSIONS: The timing of the examination influences the detection rate of CBD stones by EUS prior to surgery although it may be appropriate to more selectively use EUS in those patients with hyperbilirubinaemia and/or where the CBD is dilated.

A prospective multi-institutional study assessing clinical outcome with the NiTi compression anastomosis ring (Biodynamix ColonRingTM) in elective colorectal anastomoses.

BACKGROUND/AIMS: This 3-institution study assessed the short-term clinical outcome and safety profile of the NiTi Biodynamix ColonRingTM compression anastomosis in elective colorectal resection. METHODOLOGY: A prospective, open-label, non-randomized trial was conducted at 3 separate institutions between October 2008 to October 2009 in patients undergoing elective colorectal resection with the Biodynamix ColonRingTM compression anastomosis ring, assessing technical factors in its operative use, immediate and short-term clinical outcome parameters (length of hospital stay, time to first passage of flatus and stool and to oral intake) and peri-operative complications including anastomotic failure or stenosis and wound infection. RESULTS: Forty patients (22 females, mean age 65.9 years; range 36-83 years were included in the analysis with 14 cases being performed laparoscopically. The median duration of surgery was 120 minutes (range 60-456 minutes) with a mean anastomotic time of 14.8 minutes (range 1.75-50 minutes). The mean height of anastomosis from the anal verge was 18.2cm. The median time to passage of first flatus and first stool was 2.4 and 3.5 days, respectively with a mean hospital stay of 7.3 days. There was one postoperative death (unrelated to an anastomotic complication) with 2 anastomotic leaks (5%), 2 wound infections (5%) and no cases of early anastomotic stricture. CONCLUSIONS: The compression anastomosis ColonRingTM handles easily with an acceptable clinical outcome following both laparoscopic and open use. The incidence of anastomotic and wound complications is comparable to conventional stapled technology.