[Surgical and interventional procedures for reflux therapy : Endoscopic or laparoscopic?] / Operative/interventionelle Verfahren zur Refluxtherapie : Endoskopisch oder laparoskopisch?

An optimal functioning of the gastroesophageal antireflux barrier depends on an anatomical overlapping of the lower esophageal sphincter and the crural diaphragm. Restoration of this situation is currently only possible by antireflux interventions combined with hiatoplasty and necessitates a laparoscopic approach. Newer alternative techniques to the generally accepted fundoplication are laparoscopic implantation of the LINX® device or the EndoStim® system and various endoscopic antireflux procedures, such as radiofrequency energy treatment, plication and implantation techniques aimed at augmentation of the gastroesophageal valve. Endoscopic techniques are becoming established more and more between pharmaceutical and surgical therapy instead of replacing them.

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.

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.

Stapled hemorrhoidectomy with local anesthesia can be performed safely and cost-efficiently.

PURPOSE: This prospective study was designed to assess the feasibility of performing the procedure for prolapsing hemorrhoids, or stapled hemorrhoidectomy, under local anesthesia supplemented with conscious sedation. METHODS: Seventy consecutive patients (mean age, 56 years; 37 males) with Grade 3 or 4 hemorrhoids underwent the procedure for prolapsing hemorrhoids after perianal infiltration of 0.5 percent lidocaine with 1:200,000 epinephrine and supplemental conscious sedation. The procedure was performed in an outpatient setting, with the patient being discharged within two hours of checking into the ambulatory facility. All patients were assessed the following day by telephone, and then in the office at three weeks and two months for degree of postoperative pain, bleeding, continence, and time back to work or social activities. Additionally, all excised mucosal anastomotic rings were analyzed for presence or absence of muscle. RESULTS: Each patient rated the pain as minimal or none. Five patients complained of mild, transient perineal pressure, and three complained of fecal urgency and seepage before their first office visit; one complained of external skin tags at the second office visit. All subjects were back to work or social activities within three to four days-most within 48 hours. Complications included urinary retention in five patients, two of whom had a concomitant urinary tract infection, and one had urosepsis requiring hospitalization. One patient required immediate reoperation for bleeding from the staple line. Another patient was admitted for postoperative bleeding and packed with a hemostatic agent the evening of surgery. Muscularis propria fibers were identified in 68 of 70 pathologic specimens. CONCLUSIONS: Administration of general, spinal, or epidural anesthesia for the procedure for prolapsing hemorrhoids is well described. This study suggests that the use of local anesthesia supplemented with conscious sedation for the procedure for prolapsing hemorrhoids yields results equivalent to those achieved with general or regional anesthesia without the attendant risks and additional costs. This study also suggests that the presence of muscle fibers in the pathologic specimen does not seem to lead to increased pain or impaired continence, although it was not specifically designed to address this issue.

Use of the CEEA stapler to avoid ultra-low segmental resection of a full-thickness rectal endometriotic nodule.

A woman with a history of numerous surgical episodes for treatment of aggressive endometriosis experienced rectal symptoms. She was prepared for the possibility of laparotomy with or without colostomy to relieve her symptoms. After extensive laparoscopic dissection of the rectovaginal septum, a circular stapling device (Premium Plus CEEA; Autosuture, Melbourne, Victoria, Australia) was used to excise completely an anterior rectal lesion that otherwise would have resulted in ultra-low rectal resection and anastomosis. Morbidity associated with the latter procedure was avoided; the patient was discharged within 72 hours and experienced no early or late complications. Postoperative barium enema was obviated by rapid return to normal bowel habits and complete resolution of dyschezia and dyspareunia.