Protection of colorectal anastomosis with an intraluminal bypass device for patients undergoing an elective anterior resection: a pilot study.

BACKGROUND: Currently, the only clinically valid method to prevent morbidity and mortality related to colorectal anastomotic leaks is by construction of a protective ileostomy. Intraluminal bypass might also be a possible way to proctect the anastomosis. The aim of the present study was to evaluate the CG-100 intraluminal bypass device for the reduction of anastomosis-related morbidity and stoma creation in cases of rectal resection. METHODS: A prospective study was conducted on patients having sphincter-preserving rectal resection who were treated with the CG-100 device at Soroka University Medical Center, Beer Sheva, Israel between May 2015 and February 2017. The device was implanted during surgery and removed after 10 ± 1 days. All patients underwent a radiologic leak test with water-soluble contrast prior to removal of the device. Patients were followed for 30 days. Information about adverse events, anastomotic leaks, device usability and tolerance were collected. RESULTS: Forty-seven patients participated in the study. Most patients were operated on due to cancer 44 (93.6%). Four (9%) patients received a primary protective stoma on top of the CG-100 device as part of the learning curve of the surgical team and none required a stoma after device removal. Five (9%) serious adverse events were reported, but only 2 (4%) were classified as related to the device. One was a transient enterocutaneous fistula after removal of the device. The second was an asymptomatic radiologic leak in 1 (2.1%) patient which was treated by keeping the device in place and antibiotic treatment for another 10 days without creation of diverting ileostomy. CONCLUSIONS: CG-100 may provide a safe method for fecal diversion over a newly created anastomosis without the complications related to stoma creation and closure. A larger prospective randomized study in patients originally scheduled to receive diverting stoma is needed to confirm these findings.

The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour.

AIM: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. METHOD: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. RESULTS: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. CONCLUSION: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

Anography: a technique for determining the location of the internal opening in perianal fistula.

AIM: Anography is a radiological investigation for fistula-in-ano that identifies the primary fistula track through the internal opening. The efficacy of anography as a radiological method of identifying the location of the internal opening was investigated. METHOD: A retrospective study of 50 patients with a clinical diagnosis of fistula-in-ano of criptoglandular aetiology was performed. During anography, the location of the internal opening was recorded with respect to the quadrant of anal canal and distance from the anal verge. These data were compared with the findings during examination under anaesthesia (EUA), which was used as the gold standard for the identification of the internal opening. RESULTS: The sensitivity of anography for identifying a patent internal opening was 91% and specificity 100%. There was complete agreement between anography reports and findings at EUA regarding the quadrant of anal canal in which the internal opening was located. In more than 90% of patients, the internal opening was found at EUA within 1 cm from the site described on anography. CONCLUSION: Anography is an accurate test for predicting the exact quadrant of the anal canal in which the internal opening is located, as well as the distance of the internal opening from the anal verge. This inexpensive and simple radiological investigation should be the test of first choice in the evaluation of patients with fistula-in-ano when difficulty is anticipated in identifying the internal opening.

Assessment of sonographic quality of anal sphincter muscles in patients with faecal incontinence.

OBJECTIVE: The main application of endoanal ultrasonography (US) in evaluation of faecal incontinence is to identify surgically correctable sphincter defects. The aim of our study was to determine whether qualitative changes in echogenicity and in uniformity of internal (IAS) and external (EAS) anal sphincter muscles detected on endoanal US correlate with other anal laboratory tests and modified Wexner faecal incontinence functional score. METHOD: Records on 99 patients having complete information on anorectal manometry, faecal incontinence scoring and available endoanal US imaging of the anal sphincters were included in statistical analysis. Anatomic appearance and changes in echogenicity of the anal sphincter muscles were recorded according to the proposed scoring system. Endoanal US defect and quality component scores for IAS and EAS as well as the total score were correlated with anal laboratory tests and incontinence score using Spearman's correlations test. RESULTS: There was a trend for correlation between IAS quality score and incontinence score (P = 0.06), but no correlation for IAS defect score. EAS defect score had a significant negative correlation with maximum squeeze pressure (MSP) (P = 0.031). Distal EAS quality score had a significant correlation with incontinence score (P = 0.002). EAS total score correlated with MSP (P = 0.02) and incontinence score (P = 0.006). Endoanal US total score was significantly correlated with incontinence score (P = 0.006), maximal resting (MRP) (P = 0.035) and MSP (P = 0.045) and high pressure anal canal zone length (P = 0.03). CONCLUSION: Sonographic morphology of anal sphincter muscles correlates with anal laboratory tests and functional incontinence score. Qualitative ultrasound scoring instrument may improve evaluation of patients with faecal incontinence.

The laparoscopic option in the management of peritoneal dialysis catheter revision.

BACKGROUND: Long-term functioning of peritoneal dialysis catheters (PDCs) depends on maintenance of pelvic positioning and prevention of the formation of adhesions. The purpose of this study was to evaluate the validity of laparoscopy as a tool for the correction of malfunctioning PDCs and to introduce our specially designed technique. METHODS: The charts of 12 patients who underwent laparoscopic revisions of malfunctioning PDCs between May 1997 and June 2000 were reviewed for perioperative complications and long-term outcomes. We describe the causes of malfunction of PDCs and the laparoscopic technique for their revision. RESULTS: Of the 12 patients studied, the malfunction of eight catheters resulted from migration of the catheter into the upper abdomen. In 4 patients, formation of adhesion of either small bowel or omentum resulted in the malfunction of the PDC. The only complication we encountered was bleeding. It occurred in 3 patients, 1 of whom needed reoperation in order to achieve hemostasis. Over a median follow-up of 21 months all PDCs treated this way are functioning. CONCLUSIONS: The laparoscopic management of malfunctioning PDCs is a valid option for the treatment of such a complication.

Thoracoscopic upper thoracic sympathectomy for primary palmar hyperhidrosis--the combined paediatric, adolescents and adult experience.

OBJECTIVE: To present our experience, over the past 4 years, of thoracoscopic upper thoracic sympathectomy in patients with primary palmar hyperhidrosis. DESIGN: Retrospective study. SETTING: University hospital, Israel. SUBJECTS: 402 thoracoscopic upper thoracic sympathectomies in 223 patients over a period of 4 years. INTERVENTIONS: Thoracoscopic ablation of ganglia and severing of the sympathetic chain at the level of T2 and T3. 142 patients underwent bilateral simultaneous sympathectomy, 37 had bilateral non-simultaneous sympathectomy and 44 had unilateral sympathectomy. RESULTS: 220 patients (98.7%) had an uneventful postoperative course and were discharged the following day. Three patients with residual pneumothorax required intercostal drainage and were discharged on the third postoperative day. 219 patients (98.2%) were completely satisfied, having immediate and permanent relief of palmar sweating. Four patients were dissatisfied. CONCLUSION: The thoracoscopic approach to the upper thoracic sympathectomy is at present the procedure of choice. Early operation for severe palmar hyperhidrosis is indicated to save a child many years of frustration and discomfort.

Gastrointestinal complications of von Recklinghausen's disease: two case reports and a review of the literature.

There are few reports of the association between neurofibromatosis (von Recklinghausen's disease) and large, solid stromal tumours of the gastrointestinal tract. The prevalence of gastrointestinal involvement in von Recklinghausen's disease has been estimated at 11%-25%. Some associated gastrointestinal stromal tumours present clinically as bowel obstruction, perforation or gastrointestinal bleeding. We recently treated two patients with this condition who presented with gastrointestinal bleeding and were diagnosed with gastrointestinal stromal tumours. We report the unique aspects of these cases and discuss the diagnostic and management problems that are posed by this unusual association.