Control Comparison of the New EndoWrist and Traditional Laparoscopic Staplers for Anterior Rectal Resection with the Da Vinci Xi: A Case Study.

Background: A new robotic stapler for the da Vinci Xi® is directly controlled by the surgeon at the console and equipped with EndoWrist® technology. We evaluated operative and short-term results of the first patients who underwent anterior rectal resection for cancer with the da Vinci Xi and new staplers, and compared the results with those of a comparable group treated with traditional laparoscopic staplers. Methods: From December 2015 to December 2017, 25 patients underwent anterior rectal resection for cancer with robotic EndoWrist staplers (EndoWrist group). Using a case-control method, we compared the results with those of a similar group of patients treated with the same system and a traditional laparoscopic endostapler, controlled by a bedside assistant (Control group). Results: No conversions to laparoscopy or laparotomy were observed, in either group. The mean number of charges was 2.1 ± 0.2 in the EndoWrist group versus 2.7 ± 0.7 in the Control group (P = .0004). The other perioperative results were comparable. During follow-up, the incidence of anastomotic fistula in a contrast enema study was higher in the Control group, although the difference was not statistically significant (two leaks versus two leaks in EndoWrist group; P = .8). The interval between rectal resection and stoma closure was shorter in the EndoWrist group (3.4 ± 2.5 versus 4.2 ± 2.9 months in the Control group; P = .2), although the difference was not significant. Conclusions: Our experience suggests that the new robotic staplers simplify transection, which could reduce the average number of stapler firings used during rectal resection and could decrease the incidence of anastomotic leakage. These findings require confirmation in larger studies.

Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients.

OBJECTIVE: To assess the postoperative outcomes of patients with rectal endometriosis managed by disc excision using transanal staplers. DESIGN: Prospective study using data recorded in the CIRENDO database (NCT02294825). SETTING: University tertiary referral center. PATIENT(S): A total of 111 consecutive patients managed between June 2009 and June 2016. INTERVENTION(S): We performed rectal disc excision using two different transanal staplers: [1] the Contour Transtar stapler (the Rouen technique); and [2] the end to end anastomosis circular transanal stapler. MAIN OUTCOMES MEASURE(S): Pre- and postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. RESULT(S): The two staplers were used in 42 (37.8%) and 69 patients (62.2%), respectively. The largest diameter of specimens achieved was significantly higher using the Rouen technique (mean ± SD, 59 ± 11 mm vs. 36 ± 7 mm), which was used to remove nodules located lower in the rectum (5.5 ± 1.3 cm vs. 9.7 ± 2.5 cm) infiltrating more frequently the adjacent posterior vaginal wall (83.3% vs. 49.3%). Associated nodules involving sigmoid colon were managed by distinct procedures, either disc excision (2.7%) or segmental resection of sigmoid colon (9.9%). Postoperative values for the Gastrointestinal Quality of Life Index increased 1 and 3 years after the surgery, but improvement in constipation was not significant. The probability of pregnancy at 1 year after the arrest of medical treatment was 73.3% (95% confidence interval 54.9%-88.9%), with a majority of spontaneous conceptions. CONCLUSION(S): Disc excision using transanal staplers is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, allowing for good preservation of rectal function.

Positive detection of exfoliated colon cancer cells on linear stapler cartridges was associated with depth of tumor invasion and preoperative bowel preparation in colon cancer.

BACKGROUND: The aim of this study was to investigate exfoliated cancer cells (ECCs) on linear stapler cartridges used for anastomotic sites in colon cancer. METHODS: We prospectively analyzed ECCs on linear stapler cartridges used for anastomosis in 100 colon cancer patients who underwent colectomy. Having completed the functional end-to-end anastomosis, the linear stapler cartridges were irrigated with saline, which was collected for cytological examination and cytological diagnoses were made by board-certified pathologists based on Papanicolaou staining. RESULTS: The detection rate of ECCs on the linear stapler cartridges was 20 %. Positive detection of ECCs was significantly associated with depth of tumor invasion (p = 0.012) and preoperative bowel preparation (p = 0.003). There were no marked differences between ECC-positive and ECC-negative groups in terms of the operation methods, tumor location, histopathological classification, and surgical margins. CONCLUSIONS: Since ECCs were identified on the cartridge of the linear stapler used for anastomosis, preoperative mechanical bowel preparation using polyethylene glycol solution and cleansing at anastomotic sites using tumoricidal agents before anastomosis may be necessary to decrease ECCs in advanced colon cancer.

Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas with aneurysm-related complications.

OBJECTIVE: Aneurysm-related complications could lead to loss of a functioning arteriovenous fistula (AVF). We report our midterm and long-term results with the staple aneurysmorrhaphy technique to repair and preserve aneurysmal AVFs. METHODS: We retrospectively reviewed our surgical treatment of patients with aneurysmal autogenous AVF complicated by skin erosion, bleeding, infection, pain, and difficulty with needle access from 2007 through 2014. We identified 52 patients, 40 (77%) of whom underwent repair with the staple aneurysmorrhaphy technique. The operation involved mobilizing the entire aneurysmal segments. A TA (Covidien, Norwalk, Conn) or Endo GIA (Covidien, Mansfield, Mass) stapler was used to resect the redundant aneurysm wall to create a 6- to 8-mm-diameter conduit. A subcutaneous skin flap was created after excising compromised skin. The remodeled vein was repositioned underneath the subcutaneous flap, with the staple line rotated laterally to avoid needle puncture. RESULTS: We attempted staple aneurysmorrhaphy in 40 patients with complicated AVF aneurysms, of which 38 repairs (95%) were successful. Median patient age was 66 years (range, 29-88 years). Median AVF age was 63 months (range, 12-136 months). Median follow-up was 20 months (range, 5-81 months). At 1 year, primary patency was 67%, assisted primary patency was 88%, and secondary patency was 91%. At 2 years, primary patency was 59%, assisted primary patency was 84%, and secondary patency was 91%. At 3 years, primary patency was 46%, assisted primary patency was 69%, and secondary patency was 85%. Surgery was performed under local-regional anesthesia in 28 patients (70%) and under general anesthesia in the remaining 12 (30%). Proximal venous outflow stenoses were detected in 19 of 40 AVFs (48%) preoperatively and in 11 of 38 AVFs (29%) postoperatively. Aneurysm recurrence occurred in two repaired AVFs. CONCLUSIONS: Our experience with staple aneurysmorrhaphy shows that it is an effective, safe, and durable procedure to preserve a functioning autogenous AVF with complicated aneurysmal degeneration. Key principles are to reduce the vein to normal adjacent diameter and to provide healthy skin coverage. The remodeled AVF has a low aneurysm recurrence rate and maintains the beneficial properties of superior patency and low infection. It is important to aggressively monitor for and treat proximal outflow venous stenoses to prevent aneurysm recurrence. The surgery can be done safely under local anesthesia in selected patients.

Endoscopic anterior fundoplication with the Medigus Ultrasonic Surgical Endostapler (MUSE™) for gastroesophageal reflux disease: 6-month results from a multi-center prospective trial.

BACKGROUND: Both long-term proton pump inhibitor (PPI) use and surgical fundoplication have potential drawbacks as treatments for chronic gastroesophageal reflux disease (GERD). This multi-center, prospective study evaluated the clinical experiences of 69 patients who received an alternative treatment: endoscopic anterior fundoplication with a video- and ultrasound-guided transoral surgical stapler. METHODS: Patients with well-categorized GERD were enrolled at six international sites. Efficacy data was compared at baseline and at 6 months post-procedure. The primary endpoint was a ≥ 50 % improvement in GERD health-related quality of life (HRQL) score. Secondary endpoints were elimination or ≥ 50 % reduction in dose of PPI medication and reduction of total acid exposure on esophageal pH probe monitoring. A safety evaluation was performed at time 0 and weeks 1, 4, 12, and 6 months. RESULTS: 66 patients completed follow-up. Six months after the procedure, the GERD-HRQL score improved by >50 % off PPI in 73 % (48/66) of patients (95 % CI 60-83 %). Forty-two patients (64.6 %) were no longer using daily PPI medication. Of the 23 patients who continued to take PPI following the procedure, 13 (56.5 %) reported a ≥ 50 % reduction in dose. The mean percent of total time with esophageal pH <4.0 decreased from baseline to 6 months (P < 0.001). Common adverse events were peri-operative chest discomfort and sore throat. Two severe adverse events requiring intervention occurred in the first 24 subjects, no further esophageal injury or leaks were reported in the remaining 48 enrolled subjects. CONCLUSIONS: The initial 6-month data reported in this study demonstrate safety and efficacy of this endoscopic plication device. Early experience with the device necessitated procedure and device changes to improve safety, with improved results in the later portion of the study. Continued assessment of durability and safety are ongoing in a three-year follow-up study of this patient group.

The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin.

AIM: This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin. METHOD: A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler. RESULTS: Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence. CONCLUSION: The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an alternative to decrease the risk of recurrence and incontinence.

Protection of stapled colorectal anastomoses with a biodegradable device: the C-Seal feasibility study.

BACKGROUND: A colorectal anastomotic leak can be life-threatening. We have assessed the feasibility of a new intraluminal biodegradable bypass device that we designed to avoid anastomotic leakage and the necessity of a temporary stoma. METHODS: Fifteen patients underwent colorectal surgery. Before performing the anastomosis in a standard way, the C-Seal (Polyganics BV, Groningen, The Netherlands) was glued to the anvil of the circular stapler. Consequently, the bypass was fixated in the staple row just proximal of the simultaneously made anastomosis. A water-soluble contrast enema was performed after 1 week. RESULTS: The sheath was well compatible with the standard stapler device and easy to use. All donuts remained intact. No radiologic or clinical leaks were observed after surgery. CONCLUSIONS: This pilot study shows that the C-Seal can be applied successfully in colorectal surgery. Further investigation with large numbers of patients is now necessary to assess the efficacy of the C-Seal as a protective device.

Evidence-based management of pain after haemorrhoidectomy surgery.

BACKGROUND: Haemorrhoidectomy is associated with intense postoperative pain, but optimal evidence-based pain therapy has not been described. The aim of this systematic review was to evaluate the available literature on the management of pain after haemorrhoidal surgery. METHODS: Randomized studies published in the English language from 1966 to June 2006, assessing analgesic and anaesthetic interventions in adult haemorrhoidal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. RESULTS: Of the 207 randomized studies identified, 106 met the inclusion criteria, with mixed methodological quality. Of these, 41 studies evaluating surgical and alternative interventions were excluded. Quantitative analyses were not performed, as there were limited numbers of trials with a sufficiently homogeneous design. CONCLUSION: Local anaesthetic infiltration, either as a sole technique or as an adjunct to general or regional anaesthesia, and combinations of analgesics (non-steroidal anti-inflammatory drugs, paracetamol and opiates) are recommended. If appropriate, a stapled operation may be preferable.

Iatrogenic rectal diverticulum in patients treated with transanal stapled techniques.

PURPOSE: The aim of this study was to demonstrate the possibility of rectal diverticula developing in patients treated with endoanal circular staplers for haemorrhoids (Longo's stapled haemorrhoidectomy) or obstructed defaecation syndrome [stapled transanal rectal resection (STARR)]. MATERIALS AND METHODS: Between January 2005 and December 2006, we carried out 634 defaecographic examinations. Of these, 45 were postoperative follow-up studies of patients who had been treated with the Longo technique (n = 13) or STARR technique (n = 32). RESULTS: Seven out of 45 patients, five of whom were women treated with the Longo technique and two men with the STARR technique, developed rectal diverticula. One diverticulum was located on the left lateral rectal wall, four on the posterior wall and two on the anterior wall. All diverticula had arisen from the surgical suture point. In one case, the diverticulum was discovered incidentally during a double-contrast barium enema. One of the male patients, who had been treated with the Longo procedure 5 years earlier, developed acute pain due to faecal stasis in a widenecked diverticulum abutting the posterior rectal wall. CONCLUSIONS: The use of endorectal stapling devices can lead to focal weakness at the point of surgical suture on the rectal wall and predispose to the development of rectal diverticula.

Recurrence of colonic cancer twice at the site of stapled colorectal anastomosis.

Recurrence at the site of a stapled anastomosis is generally believed to result from the luminal implantation of viable cancer cells during stapling. We report a case in which colon cancer recurred twice at the site of a stapled anastomosis, despite povidone iodine (PVP-I) lavage consisting of an enema with 5% PVP-I solution before the operation and intraoperative lavage of the rectal remnant and the descending colon with a 10% PVP-I solution. Three months after sigmoidectomy to resect a carcinoma of the sigmoid colon, a circular anastomotic recurrence was found at the suture line after anastomosis with a stapler. However, 11 months after the subsequent resection and reanastomosis to remove the first anastomotic recurrence, another anastomotic recurrence was found. We performed abdominoperineal resection for the second recurrence at the site of the stapled anastomosis. Suture-line recurrence could not be prevented in the present case despite lavage with a PVP-I solution for prophylaxis.

Stapled transanal rectal resection (STARR) to reverse the anatomic disorders of pelvic floor dyssynergia.

Anterior rectocele and rectoanal intussusception are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation. Stapled transanal rectal resection (STARR), a newly described surgical method for correcting these disorders, is considered a good alternative to the traditional transrectal approaches. The aim of the present study was to assess the early postoperative functional results of STARR. A total of 16 patients (13 female) were subjected to the STARR procedure during a period of 12 months. The presence of anatomic disorders of the anorectum was verified by dynamic defecography. Preoperative assessment also included colonic transit time, anal sphincter ultrasonography, and anorectal stationary manometry. Postoperative assessment included the same battery of tests. Altogether, 12 patients had rectoanal intussusception of > 2 cm and rectocele. In eight of them the anterior component of the rectocele was 2 to 4 cm, and in four it was > 4 cm. Four patients had a 1- to 2-cm internal intussusception and a rectocele of < 2 cm. All of them reported evacuation difficulties, but none had significant incontinence. Preoperative endoscopy did not reveal the presence of a solitary ulcer in any of the patients. All females had had normal vaginal deliveries, and four of them were multiparous. No complications were encountered postoperatively, and the need for analgesics was minimal. At defecography, rectoanal anatomy was seen to be restored in all patients. Obstructive defecation symptoms remained rather unaffected in seven, disappeared in three, and improved significantly in the remaining six patients. The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in five of them. Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attributed to coexisting enterocele, which had been missed preoperatively. Immediately after surgery, most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3 to 5 weeks in all but two cases. STARR is a safe, well tolerated surgical procedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception. Additional biofeedback treatment is usually necessary for further functional improvement. Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic floor.

Transoral diverticulostomy with a modified Endo-Gia stapler: results after 4 years of experience.

BACKGROUND: The incidence of Zenker's diverticulum is low (2/100,000). Standard surgical treatment is cricopharyngeal myotomy with diverticulectomy. Various minimally invasive surgical approaches pursued recently have treated Zenker's diverticulum adequately. The functional minimally invasive therapy is performed alternatively using an Endo-Gia stapler inserted transorally to perform an esophageal diverticulostomia, or using thermal coagulation applied by a carbon dioxide (CO2) or argon plasma laser. The key to a successful procedure is adequate exposure of the diverticulum by insertion of a pharynx spreader before the surgery. METHODS: Since 1996, 31 patients who underwent minimally invasive diverticulostomies performed in our clinic have been included prospectively in the current study. All the patients were examined endoscopically before and after surgery. Furthermore, the intraesophageal and intragastric pressure was examined by transesophageal manometry, and the pH in the esophagus and stomach was determined by pH-metry. A barium swallow was performed to exclude leakage at the stapler suture line as proof of sufficient anastomoses. Manometry showed that the upper esophageal sphincter functioned normally before and after surgery. The results were compared with those of patients undergoing conventional procedures. RESULTS: The median follow-up period after resection of the diverticulum was 46 months. Both the Gastrointestinal Quality-of-Life Index (GQLI) (p < 0.001) and the modified dysphagia score (GHDS) increased significantly, indicating that the operations were successful. The minimally invasive procedure is faster than cricopharyngeal myotomy and significantly safer. It is better tolerated by patients, and they are discharged earlier. CONCLUSION: Transoral esophagodiverticulosomy has become the standard procedure for Zenker's diverticulum in the authors' department. The endoscopic minimally invasive approach proved to be safer than standard surgical procedures. It offers a significantly shorter operation time and postoperative hospital stay (p < 0.001).

Validation of the NITI Endoluminal Compression Anastomosis Ring (EndoCAR) device and comparison to the traditional circular stapled colorectal anastomosis in a porcine model.

The purpose of this study was to determine whether the characteristics of compression anastomoses created by a new device are comparable to existing stapler technology. A total of 18 pigs were studied, and each served as its own control using a 27-mm compression device and a 29-mm stapler. Anastomoses were randomized to proximal and distal positions along the rectum and were separated by 10 cm. Six nonsurvival pigs were sacrificed at zero time to failure test the anastomoses. Twelve pigs were sacrificed at 14 days. Failure pressures, circumferences, and radiographic leak rates were determined. Anastomotic tissue was processed for matrix metalloproteinase, collagen, and elastin levels. The compression anastomoses had higher mean failure pressures than stapled anastomoses at zero time (103 vs 29.9 mm Hg). At 2 weeks, there was no difference between failure pressures (256 vs 250 mm Hg). During burst testing, 3 of the compression anastomoses failed at the anastomosis at 2 weeks, whereas none of the stapled anastomoses failed. The mean anastomotic circumference of the compression anastomoses was narrower than the stapled anastomoses (9.63 vs 11.25 cm, P = .001). There were no clinical leaks or radiographic leaks by barium enema at 2 weeks. There was no difference between matrix metalloproteinase, collagen, or elastin content based on tissue analysis. There were dense adhesions to 7 of 12 (58.3%) of the stapled anastomoses, whereas only 1 of 12 (8.3%) of the compression anastomoses had flimsy adhesions. A new compression anastomosis technique using a nickel-titanium alloy may be an advance in technology by reducing leaks and eliminating foreign material in the anastomosis.

Surgical treatment of Chagasic megacolon by abdominal rectosigmoidectomy with immediate posterior end-to-side stapling (Habr-Gama technique).

PURPOSE: Various techniques have been used in the surgical treatment of Chagasic megacolon, including sympathectomy, sphincterotomy, anterior abdominal resection with high or low anastomosis, pull-through procedures, and Duhamel technique. However, results have not been consistently satisfactory, with reportedly high morbidity and mortality rates. The purpose of this study was to assess the technique and results of anterior rectosigmoidectomy with immediate posterior colorectal end-to-side stapled anastomosis for the treatment of Chagasic megacolon. METHODS: A prospective, noncontrolled study between 1989 and 2000 analyzed 49 patients with Chagasic megacolon. Preoperative barium enema confirmed Chagasic megacolon in all patients and preoperative anorectal manometry in 33 patients (67 percent). Rectal stump closure was undertaken by surgical stapling in 41 patients (84 percent); mechanical colorectal anastomosis was accomplished with a circular stapler in all patients. RESULTS: Symptoms of intestinal constipation ranged from 6 months to 40 years, Chagas' serology was positive in 98 percent of patients, 41 percent used bowel enemas for evacuation, and 71 percent had a history of fecaloma. The overall postoperative complication rate was 20 percent. Surgical complications occurred in 18 percent, 2 percent had nonsurgical complications, and there was no mortality. Postoperative barium enema was performed in 82 percent of cases, confirming the absence of disease. Postoperative anorectal manometry demonstrated normal resting pressure and rectal capacity; the inhibitory reflex remained absent and rectal sensitivity was increased. Ninety-three percent of patients were followed for more than 48 months, and all patients reported daily stool elimination without recurrence of constipation. CONCLUSIONS: The current study indicates that our technique is effective for surgical treatment of patients with Chagasic megacolon.

[Obstructed defecation]. / Defäkationsobstruktion.

Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.

[Septic shock caused by perforation of sigmoid diverticulum into the Retzius space. A case report]. / Shock settico da perforazione di un diverticolo del sigma nello spazio del Retzius. Descrizione di un caso clinico.

An uncommon complication of the sigmoid diverticulitis personally observed is described. A woman, 59 years old, presented a septic shock caused by perforated sigmoid diverticulum into the space of Retzius. The diagnosis was carried out by an X-ray of the abdomen that suspected the presence of air in the retroperitoneum and then by barium enema showing a perforation of the sigmoid colon. During laparotomy a perforation of sigmoid diverticulum in to the space of Retzius was observed. So the space of Retzius was opened and then pus and watery exudate containing bubbles of gas were found extended also to the retroperitoneum and the right abdomen wall. The patient was submitted to a sigmoid resection; bowel continuity was restored by circular stapled anastomosis and a temporary colostomy was made. Some drainages were placed into the space of Retzius, into the retroperitoneum and into the peritoneal cavity. Nevertheless the patient died because of the septic shock and the postoperative MOF.

Modified technique of antegrade continence enema using a stapling device.

PURPOSE: We present a stapling technique for constructing an antegrade continence enema (ACE) conduit that is helpful in cases of insufficient appendiceal luminal length or when a concomitant appendiceal Mitrofanoff stoma is required. MATERIALS AND METHODS: In 6 patients with a mean age of 9.5 years who required an ACE procedure the cecum was tubularized in continuation with the orthotopic appendix at its base, using a stapling device to construct an ACE conduit. The tubularized segment was imbricated with permanent suture material. In 3 cases appendiceal length after tubularization was sufficient to allow splitting for the concomitant creation of an appendiceal Mitrofanoff stoma. RESULTS: Patients have been followed an average of 16.5 months. Stomal continence was achieved in all cases as well as reliable catheterization of the appendiceal cecostomy in 6 and the Mitrofanoff conduit in 3. CONCLUSIONS: This modification of the ACE procedure with cecal tubularization in continuation with the appendix using a stapling device is an excellent approach in cases of inadequate appendiceal length. It successfully creates a catheterizable stoma with a reliable flap valve continence mechanism. The complex reconstructive procedure is simplified by eliminating the need to use tapered small intestine, while allowing the creation of a concomitant appendiceal Mitrofanoff stoma as necessary.

Nefrectomía del donante vivo: nefrectomía laparoscópica y otras alternativas mínimamente invasivas / Live donor nephrectomy: laparoscopic nephrectomy and other minimally invasive alternatives

El trasplante de vivo es la alternativa terapéutica de la insuficiencia renal terminal que ofrece los mejores resultados de supervivencia de injerto y paciente. La nefrectomía del donante por una incisión abierta conlleva una morbilidad importante y una mortalidad estimada del 0,03` por ciento, con un largo período de recuperación. Las técnicas quirúrgicas mínimamente invasivas aplicadas en el donante vivo de riñón intentan disminuir la morbilidad y el período de recuperación de la cirugía. La nefrectomía laparoscópica del donante vivo ha demostrado ser una técnica eficaz para disminuir la morbilidad y el período de recuperación de los donantes. La técnica permite obtener un riñón en perfectas condiciones para el trasplante, con resultados similares de supervivencia. La desventaja principal es su dificultad con una curva de aprendizaje larga, asociada con un riesgo mayor de complicaciones ureterales en el receptor. La nefrectomía laparoscópica asistida manualmente permite la introducción de la mano del cirujano en el abdomen del paciente, facilitando la cirugía a aquellos con menor experiencia laparoscópica. Otras alternativas en uso son la retroperitoneoscopia y las técnicas abiertas por vía anterior retroperitoneal sin excisión costal (AU)

Longterm outcomes and quality of life after Z-shaped anastomosis for Hirschsprung's disease.

BACKGROUND: Z-shaped anastomosis is one of the modifications of Duhamel's procedure that was designed to eliminate the blind rectal pouch and to achieve complete resection of the colorectal septum. It has been the most widely performed operation in Japan for many years. The longterm postoperative function of evacuation and quality of life of the patients are considered important to evaluate this procedure. METHODS: At Kyushu University Hospital, from 1963 to 1997, 127 patients with Hirschsprung's disease underwent Z-shaped anastomosis. As a result, 122 out of 127 patients (96%) survived. The present status and symptoms, and anorectal functions, including a manometric study and barium enema, were evaluated during the clinical followup. RESULTS: A total of 99 of the 122 surviving patients (81%) were available for this study, and the mean postoperative period was 16 years. Evacuation scores in all patients were as follows; excellent, 62.2%; good, 28.6%; fair, 8.2%; and poor, 1.0%. The percentage of the patients who showed severe symptoms was 4.1% for diarrhea, 3.1% for constipation, 5.1% for incontinence, and 7.1% for soiling. The evacuation score improved chronologically and tended to reach a plateau at 10 to 15 years after operation, at which time 73% of the patients showed excellent outcomes and 95% were satisfactory (good or excellent). The appearance of a sense of defecation and an increase in the pressure difference between the anal canal and the rectum substantially contributed to the improvement in the defecation score. The appearance of the rectosphincteric reflex, including the atypical one, was seen in 40.5% of patients, but the appearance of a reflex did not seem to be related to the clinical status of defecation. Twenty-two of 30 patients older than 20 years were married, and 8 patients had children. CONCLUSIONS: The evacuation scores of in-patients undergoing Z-shaped anastomosis improved with age and were satisfactory (good or excellent) in most patients at least 10 years after operation. Most of the patients adapted to a normal social life.