Mechanotechnical faults and particular issues of anastomotic complications following robot-assisted anterior resection in 968 rectal cancer patients.

BACKGROUND: As most risk factors for anastomotic complications (AC) in rectal cancer patients appear to be noncorrectable, it is needed to find the correctable causes. Additionally, the outcomes of indocyanine-green fluorescence imaging (IFI) and robot-stapled anastomosis have yet been undetermined. METHODS: This study retrospectively analyzed 968 consecutive patients with rectal cancer, who underwent curative robot-assisted anterior resections between 2010 and 2018. IFI parameters and stapling features in the surgical records were reviewed, and reconfirmed. RESULTS: AC occurred in 54 patients (5.6%), 34 (3.5%) with anastomotic leakage (AL) and 24 (2.5%) with anastomotic stenosis (AS). Mechanotechnical faults including defective stapling configurations, including angles lesser than or equal to 150° and outer deviation (more than half from the center of the circle) of linear staples, between the two linear staples were independently associated with AL (P < .001 each). IFI significantly reduced AL rate (2.5% vs 5.3%, P = .029) and AS rate (2% vs 18.8%, P = .006), respectively. Robot linear stapling enabled to maintain the obtuse angle during consecutive staplings and reduced console time. AL and AS were independent risk factors for disease-free survival (P = .02) and local recurrence (P = .03), respectively. CONCLUSIONS: AC were associated with some correctable causes, namely, mechanotechnical errors and lack of use of IFI.

[Endovascular treatment of a patient with post-thrombotic disease and obstruction of a cava filter]. / Éndovaskuliarnoe lechenie bol'nogo s posttromboticheskoi bolezn'iu i obstruktsiei kava-fil'tra.

Balloon angioplasty and stenting have increasingly been gaining widespread application for treatment of post-thrombotic alterations in the system of the vena cava. Endovascular ultrasonographic examination makes it possible with the utmost degree of reliability to determine both the extension and degree of the narrowing of venous segments, thus proving a possibility of choosing a venous stent of an appropriate diameter. Restoration of an adequate venous lumen leads to normalization of blood flow and elimination of venous hypertension. However, unsolved as yet remains the problem concerning proper management of post-thrombotic obstructions of the inferior vena cava at the level of a cava filter. Owing to a wide variety of configurations of cava filters to deploy, there are no common approaches to elimination of such obstruction. Presented herein is a clinical case report regarding successful endovascular treatment of a patient diagnosed with post-thrombotic disease secondary to endured thrombosis. The findings of both phlebography and endovascular ultrasonographic examination made it possible to diagnose obstruction of the left common iliac vein, external iliac vein, and inferior vena cava to the level of the cava filter previously deployed. In the segment of the inferior vena cava at the level of the cava filter also revealed was a pronounced luminal narrowing exceeding 90% of its diameter. We carried out stenting of the common and external iliac veins, inferior vena cava, and the cava filter. Swelling of the left leg subsided spontaneously within 2 weeks and the first postoperative month was accompanied by gradual disappearance of the previously existing feeling of heaviness in the lower limbs and a dramatic decrease in fatigue by the end of the working day.

Ischemic or toxic injury: A challenging diagnosis and treatment of drug-induced stenosis of the sigmoid colon.

A 48-year-old woman was admitted with 15-mo history of abdominal pain, diarrhea and hematochezia, and 5-mo history of defecation difficulty. She had been successively admitted to nine hospitals, with an initial diagnosis of inflammatory bowel disease with stenotic sigmoid colon. Findings from computed tomography virtual colonoscopy, radiography with meglumine diatrizoate, endoscopic balloon dilatation, metallic stent implantation and later overall colonoscopy, coupled with the newfound knowledge of compound Qingdai pill-taking, led to a subsequent diagnosis of ischemic or toxic bowel disease with sigmoid colon stenosis. The patient was successfully treated by laparoscopic sigmoid colectomy, and postoperative pathological examination revealed ischemic or toxic injury of the sigmoid colon, providing a final diagnosis of drug-induced sigmoid colon stenosis. This case highlights that adequate awareness of drug-induced colon stenosis has a decisive role in avoiding misdiagnosis and mistreatment. The diagnostic and therapeutic experiences learnt from this case suggest that endoscopic balloon expansion and colonic metallic stent implantation as bridge treatments were demonstrated as crucial for the differential diagnosis of benign colonic stenosis. Skillful surgical technique and appropriate perioperative management helped to ensure the safety of our patient in subsequent surgery after long-term use of glucocorticoids.

Impact of Preoperative Radiotherapy on Anastomotic Leakage and Stenosis After Rectal Cancer Resection: Post Hoc Analysis of a Randomized Controlled Trial.

BACKGROUND: Evidence regarding the effect of preoperative radiotherapy on anastomotic integrity remains conflicting in rectal cancer surgery. Prospective comparisons with appropriate controls are needed. OBJECTIVE: This study aimed to assess the impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection. DESIGN: This was a post hoc analysis of a randomized controlled trial (NCT01211210). SETTINGS: Data were retrieved from the leading center of the trial, which is a tertiary hospital. PATIENTS: The full analysis population of 318 patients was included. INTERVENTIONS: Patients were randomly assigned to receive preoperative radiation (50 Gy per 25 fractions) and 5-fluorouracil infusion, alone (arm A) or combined with oxaliplatin (arm B), or preoperative chemotherapy with 5-fluorouracil and oxaliplatin without radiation (arm C). MAIN OUTCOME MEASURES: The rates of anastomotic leakage and stenosis were calculated for each treatment arm. Multivariate analysis was used to verify the effect of preoperative radiotherapy. RESULTS: The treatment arms were comparable in terms of most baseline characteristics, but more diversions were used in the chemoradiotherapy arms. Anastomotic leakage occurred in 20.2% of patients in arm A, 23.6% of patients in arm B, and 8.5% of patients in arm C (p = 0.007). The corresponding rates of stenosis were 17.0%, 18.9%, and 6.8% (p = 0.02). Multivariate analysis confirmed the correlation between preoperative radiotherapy and clinical leakage (p = 0.02), which was associated with delayed stenosis (p < 0.001). For patients undergoing chemoradiotherapy, radiation proctitis was identified as an independent risk factor for clinical leakage (p = 0.01) and stenosis (p < 0.001). LIMITATIONS: The main limitations were discrepancies in stoma creation and chemotherapy regimen among the treatment arms. CONCLUSIONS: Preoperative radiotherapy increases the risk of anastomotic leakage and stenosis after rectal cancer resection. Clinical leakage independently contributes to the development of stenosis.

Effects of tripterygium glycosides on restenosis following endovascular treatment.

The mechanism and associated factors of restenosis following intravascular stent implantation remain to be elucidated. The present two­part experimental and clinical study aimed to investigate the effects of tripterygium glycosides on in­stent restenosis subsequent to intra­arterial therapy. Following endovascular stent implantation in rabbit iliac arteries, post­stent outcomes were evaluated in cyclosporine groups, low­dose and high­dose tripterygium glycosides groups and controls. Post­operative angiography indicated that vessel diameters were similar between groups; however, at 28 days after receiving the therapeutic agents, vessels of the cyclosporine and tripterygium glycosides groups were significantly larger than those of the controls. Furthermore, three groups of patients had comparable baseline levels of interleukin (IL)­10, IL­18 and C­reactive protein, and intima­media thickness. However, 1 month after stent implantation, levels of IL­10 and IL­18 were markedly reduced in the high­ and low­dose tripterygium glycosides groups compared with controls. At 6 months after surgery, the stent patency rate in patients with bare stents was significantly lower than in patients receiving tripterygium glycosides (P≤0.009). In addition, the ankle­brachial index was also higher than in those without tripterygium glycosides (P<0.001). Results of the experimental and clinical studies suggest that tripterygium glycosides may inhibit and possibly aid in the prevention of in­stent restenosis formation following endovascular treatment of lower­extremity artery disease.

The 5-year outcome of patients having incomplete colonoscopy.

AIM: Incomplete colonoscopy indicated for the detection of neoplasia occurs in 2-23% of patients, but there is little information on the long-term outcome of such patients. METHOD: All patients who underwent colonoscopy over 5 years at the Royal Liverpool University Hospital with a follow-up of up to 5 years were identified. RESULTS: The risk of colorectal cancer (CRC) was 2.9% (312/10 580) for all patients undergoing colonoscopy. For a failed colonoscopy, the risk was five-fold higher [14.3% (99/693)]. The mean age of the patients was 61 years and 58% were female. Following incomplete colonoscopy the risk of finding additional CRC, advanced colonic neoplasia and extracolonic neoplasia on subsequent investigation was 6.2%, 3.2% and 1.9%. The diagnostic yield on subsequent investigation for CRC or colonic polyps was 7% for repeat colonoscopy, 13.4% for computed tomography colonography, 10.3% for standard computed tomography and 1.8% for barium enema. In the 363 patients who were not offered a subsequent investigation, there was no further instance of CRC or CRC-related mortality over a 36-month period. CONCLUSION: Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.

Colonic stenosis caused by infection of an intraperitoneal access port system: a rare complication of intraperitoneal chemotherapy for gastric cancer with peritoneal metastasis.

BACKGROUND: Intraperitoneal (i.p.) chemotherapy is garnering attention as an effective treatment for gastric cancer with peritoneal metastasis. We report the case of a patient who developed colonic stenosis caused by infection of an i.p. access port system during i.p. chemotherapy. It was difficult to differentiate whether the extrinsic colonic stenosis arose from a catheter infection or peritoneal metastasis of the gastric cancer. CASE PRESENTATION: A 66-year-old Japanese man underwent total gastrectomy for gastric cancer. Because the intraoperative findings revealed peritoneal metastasis, a port system was implanted for subsequent i.p. chemotherapy. Two months after initiation of chemotherapy, he complained of vomiting and abdominal pain. A computed tomography scan revealed marked thickening of the sigmoid colon wall adjacent to the catheter of the i.p. access port system. A barium enema demonstrated extrinsic irregular stenosis of the sigmoid colon. Although it was difficult to distinguish whether infection or peritoneal metastasis had caused the colonic stenosis, we removed the port system to obtain a therapeutic diagnosis. Coagulase-negative staphylococci were detected by catheter culture. The wall thickening and stenosis of the sigmoid colon completely resolved after removal of the port system. CONCLUSIONS: We report the case of a rare complication in association with an i.p. access port system. Infection of the port system should be considered as a differential diagnosis when colonic stenosis adjacent to the catheter is observed during i.p. chemotherapy.

Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment.

Intracranial atherosclerosis is one of the most common causes of stroke worldwide and is associated with a high risk of recurrent stroke. New therapeutic approaches to treat this high-risk disease include dual antiplatelet treatment, intensive management of risk factors, and endovascular therapy. Early data from randomised trials indicate that aggressive medical therapy is better than stenting for prevention of recurrent stroke in high-risk patients with atherosclerotic stenosis of a major intracranial artery. Nevertheless, there are subgroups of patients who remain at high risk of stroke despite aggressive medical therapy. Further research is needed to identify these high-risk subgroups and to develop more effective treatments. Non-invasive vascular imaging methods that could be used to identify high-risk patients include fractional flow on magnetic resonance angiography (MRA), quantitative MRA, and high-resolution MRI of the atherosclerotic plaque. Alternative therapies to consider for future clinical trials include angioplasty alone, indirect surgical bypass procedures, ischaemic preconditioning, and new anticoagulants (direct thrombin or Xa inhibitors).

Endoscopic therapy in inflammatory bowel diseases (with videos).

Endoscopic therapies are important modalities in the treatment of IBD, adjunct to medical and surgical approaches. These therapeutic techniques are particularly useful in the management of IBD-associated or IBD surgery­associated strictures, fistulas, and sinuses and colitis-associated neoplasia. Although the main focus of endoscopic therapies in IBD has been on balloon stricture dilation and ablation of adenoma-like lesions, new endoscopic approaches are emerging, including needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement, and fistula tract injection. Risk management of endoscopy-associated adverse events is also evolving. The application of endoscopic techniques in novel ways in the treatment of IBD is just beginning and will likely expand rapidly in the near future.

Neurogenic stunned myocardium after acute hydrocephalus.

Neurogenic stunned myocardium (NSM) is a syndrome of cardiac stunning after a neurological insult. It is commonly observed after aneurysmal subarachnoid hemorrhage but is increasingly being reported after other neurological events. The underlying mechanism of NSM is believed to be a hypothalamic-mediated sympathetic surge causing weakened cardiac contractility and even direct cardiac myocyte damage. The authors report 2 cases of NSM in pediatric patients after acute hydrocephalus. Both patients experienced severe cardiac dysfunction in the acute phase but ultimately had a good neurological outcome and a full cardiac recovery. The identification, treatment, and outcome in 2 rare pediatric cases of NSM are discussed, and the history of the brain-cardiac connection is reviewed.

Cáncer del ángulo esplénico del colon: presentación de un caso / Cancer of the colon spleen angle: presentation of a case

El cáncer de colon es actualmente un importante problema de salud pública en los países desarrollados. Es el cuarto cáncer más frecuente en el mundo. Reportamos un caso de una paciente femenina, de 65 años de edad, raza negra, que acude a la consulta por presentar trastornos dispépticos como único síntoma, sin factores de riesgo conocido. Se le indicó un colon por enema, en el que se observó un estrechamiento distal al ángulo esplénico del colon en la misma zona de la estrechez fisiológica a ese nivel. Se le realizó colonoscopia que diagnostica: tumor de colon izquierdo próximo al ángulo esplénico. Se operó y se le realizó la resección segmentaria de ángulo esplénico, así como biopsia. Anatomía patológica informa adenocarcinoma del colon bien diferenciado.

The colon cancer is currently an important public health problem in developed countries. It is the fourth most common cancer in the world. We report the case of a 65-years-old, black, female patient, assisting our consultation with dyspeptic disturbances as the unique symptom, without known risk factors. We indicated a colon by enema and a distal narrowing was observed at the colon spleen angle, at the same zone of the physiologic narrowing at that level. A colonoscopy was carried out diagnosing a left colon tumor near the spleen angle. It was operated with segmental resection of the spleen angle and a biopsy was made. Pathologic anatomy informed a well-differentiated colon adenocarcinoma.

Cáncer del ángulo esplénico del colon: presentación de un caso / Cancer of the colon spleen angle: presentation of a case

El cáncer de colon es actualmente un importante problema de salud pública en los países desarrollados. Es el cuarto cáncer más frecuente en el mundo. Reportamos un caso de una paciente femenina, de 65 años de edad, raza negra, que acude a la consulta por presentar trastornos dispépticos como único síntoma, sin factores de riesgo conocido. Se le indicó un colon por enema, en el que se observó un estrechamiento distal al ángulo esplénico del colon en la misma zona de la estrechez fisiológica a ese nivel. Se le realizó colonoscopia que diagnostica: tumor de colon izquierdo próximo al ángulo esplénico. Se operó y se le realizó la resección segmentaria de ángulo esplénico, así como biopsia. Anatomía patológica informa adenocarcinoma del colon bien diferenciado...(AU)

Evaluation of endoscopic and imaging modalities in the diagnosis of structural disorders of the ileal pouch.

BACKGROUND: Computerized tomography enterography (CTE), gastrograffin enema (GGE), magnetic resonance imaging (MRI), and pouch endoscopy (PES) have commonly been used to assess ileal pouch disorders. However, their diagnostic utility has not been systematically evaluated. The aims of this study were to compare these imaging techniques to each other and to optimize diagnosis of pouch disorders by using a combination of these diagnostic modalities. METHODS: Clinical data of patients from the Pouchitis Clinic from 2003 to 2008 who had a PES and at least 1 additional imaging modalities (CTE, GGE, or MRI) used for evaluation of ileal pouch disorders were retrospectively evaluated. We analyzed the accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) with which these tests were able diagnose pouch inlet and distal small bowel and pouch outlet strictures, pouch fistulas, sinuses, and leaks. Subsequently, accuracy was recalculated by combining 2 imaging modalities to see if this could enhance accuracy. RESULTS: A total of 66 patients underwent evaluation with PES and 1 other imaging modality as follows: PES + CTE (n = 23), PES + GGE (n = 34), and PES + MRI (n = 26). The mean age was 41.5 +/- 14.5 years, with 28 being female (42.4%). Sixty patients (90.9%) had J pouches and 59 (89.4%) had a preoperative diagnosis of ulcerative colitis. Overall, CTE, GGE, MRI, and PES all had reasonable accuracy for the diagnosis of small bowel and inlet strictures (73.9%-95.4%), outlet strictures (87.9%-92.3%), fistula (76.9%-84.8%), sinus (68.0%-93.9%), and pouch leak (83-93.9%). CTE had the lowest accuracy for small bowel and inlet strictures (73.9%) and MRI had the lowest accuracy for pouch sinus (68.0%). Combining 2 imaging tests can increase the accuracy of diagnosis to 100% for strictures, fistulas, sinus, and pouch leaks. CONCLUSIONS: CTE, GGE, MRI, and PES offer complementary information on disorders of the pouch and the combination of these tests increases diagnostic accuracy for complex cases.

[Membranous constriction of the colon caused by non-steroidal anti-inflammatory drugs--case report]. / Nem szteroid gyulladáscsökkentó gyógyszer indukálta membranosus vastagbélszúkület--esetismertetés.

A 79-year-old female patient with rheumatoid arthritis treated with NSAIDs on long-term developed iron-deficiency anaemia and subsequently subacute intestinal obstruction. Barium enema showed multiple diaphragm-like strictures. At colonoscopy the lumen of the ascending colon was divided into compartments by multiple thin circumferential mucosal membranes. Right hemicolectomy was carried out. The histology of the resected specimen confirmed diaphragm disease of the large bowel. Diagnosis is usually difficult, even at laparotomy, due to the poor external presence of the disease. Such lesions are rare (about 10 cases have been reported in the world literature) and are similar to those previously described in the small bowel. With the increasing world-wide use of NSAIDs, clinicians must be aware of this rare gastrointestinal complication, which may require emergency surgical intervention.

Identification of atrial tissue in pulmonary veins using intravascular ultrasound.

BACKGROUND: Atrial fibrillation (AF) is initiated by ectopic beats originating in the sleeve of atrial tissue in pulmonary veins (PVs). Circumferential ablation of PVs can, thus, result in a cure of AF. Identification of this PV arrhythmogenic tissue has been exclusively on the basis of electrophysiologic recordings. The purpose of this study was to visualize this tissue using intravascular ultrasound (IVUS). Methods and results In all, 15 patients undergoing AF ablation had IVUS studies of their PVs. A total of 21 veins had a wall thickness less than 0.1 mm, whereas 31 veins had well-demarcated areas of thickening measuring 0.81 +/- 0.32 mm. Electrophysiologic recordings from these thickened areas showed typical high-frequency potentials associated with arrhythmogenic atrial tissue in the PVs. Ectopic beats initiating AF always originated from these areas. PVs without thickening on IVUS did not have these potentials. CONCLUSIONS: IVUS permits visualization of atrial tissue in the PVs, and arrhythmogenic PVs are qualitatively and quantitatively different from nonarrhythmogenic PVs.

Hyperbaric oxygen therapy in two patients with non-arteritic anterior optic neuropathy who did not respond to prednisone.

Recent advances in understanding the effects of hyperbaric oxygen (HBO) on retinal anoxia gave rise to new interest in the possibility of using it as therapeutic treatment for ischemic conditions of the retina and optic nerve. Two patients with non-arteritic anterior ischemic optic neuropathy due to a high-grade ophthalmic artery stenosis were treated with HBO at 2 atm abs in an effort to increase oxygen delivery for the eye. Both patients showed marked improvements of visual acuity and visual field 3-5 months following the event. Our results are intriguing although the achieved improvement could be coincidental.

[Usefulness of CT colonography in the preoperative evaluation of patients with distal occlusive colorectal carcinoma]. / Ruolo della colonscopia virtuàle con Tomografia Computerizzata nella valutazione preoperatoria dei pazienti con carcinoma stenosante del colon-retto.

PURPOSE: To evaluate the role of preoperative virtual colonoscopy to study the proximal colon in patients with distal occlusive carcinomas, diagnosed by conventional colonoscopy. MATERIAL AND METHODS: We examined 19 patients aged 46 to 83 years (13 men and 6 women) with distal occlusive colorectal carcinomas diagnosed by conventional colonoscopy, who were preoperatively studied with virtual colonoscopy. Patients with acute bowel obstruction were excluded. Results were compared with the findings of preoperative conventional colonoscopy and barium enema examination, intraoperative colon palpation, histopathologic outcome, postoperative conventional colonoscopy and barium enema examination. RESULTS: Virtual colonoscopy identified all 19 distal occlusive colon carcinomas and 22 synchronous lesions, 2 cancers (prevalence 10,6%) and 20 polyps (prevalence 68,4%). Both synchronous cancers were confirmed intraoperatively by direct palpation. Postoperative conventional colonoscopy, which was performed in 18 patients, confirmed the presence of 15 polyps in 12 patients. Three subcentimeter polyps were removed during conventional colonoscopy and were missed at virtual colonoscopy. Two polyps shown by virtual colonoscopy were not found at conventional colonoscopy. Postoperative barium enema was performed in three patients and confirmed three polyps identified at virtual colonoscopy. Preoperative barium enema was performed in five patients and failed to adequately demonstrate the proximal colon. Virtual colonoscopy showed a sensitivity of 87% and a specificity of 75%. CONCLUSIONS: Virtual CT colonoscopy can be considered an important diagnostic technique to evaluate preoperatively the proximal colon in patients with distal occlusive carcinomas,as it gives better results than barium enema or conventional colonoscopy, as well as being well tolerated and less invasive.

[Stenotic endometriosis of the sigmoid. Apropos a case]. / L'endometriosi stenosante del sigma. A proposito di un caso.

The authors report a rare case of stenotic sigmoid endometriosis which presented with constipation and dysmenorrhea in a 48-year-old woman without past gynecological history. There were no typical radiological and endoscopic findings and only pathological examination revealed endometriosis. The patient did well after sigmoid resection and bilateral salpingo-oophorectomy and has had no further complaints. The authors stress the rare location of the disease and review the literature about etiopathogenetic hypotheses and pathological features. The diagnostic value of clinical examination, barium enema and colonoscopy is low as endometriosis rarely involves the mucosa. This case led the authors to discuss about diagnostic difficulties, differential diagnosis and therapeutic options.

[The hydro-MRT of chronic inflammatory bowel diseases]. / Hydro-MRT chronisch entzündlicher Darmerkrankungen.

PURPOSE: Evaluation of hydro-MRI in the diagnosis of chronic inflammatory bowel disease (IBD). MATERIAL AND METHODS: 33 patients with suspected Crohn's disease or ulcerative colitis were studied prospectively. After distension of the colon by a rectal enema, breathhold MR imaging was performed during bowel relaxation. Results were compared to the clinical diagnosis, endoscopy, barium studies and histopathology. RESULTS: 24/24 patients with active Crohn's disease were correctly diagnosed by MRI. Conversely, MRI was positive in only 2/5 patients with ulcerative colitis. In 5 patients the presence of IBD was excluded. There were no false positives. CONCLUSION: Hydro-MRI is a very reliable modality in the diagnosis of Crohn's disease. In the differentiation of Crohn's disease from ulcerative colitis, hydro-MRI seems to be a promising imaging procedure.