Anastomotic stenosis after coloanal, colorectal and ileoanal anastomosis: what is the best management?

AIM: To assess the results of treatment for colorectal (CRA), coloanal (CAA) or ileal pouch-anal (IPAA) anastomotic stenosis (AS). METHOD: All patients operated on for AS from 1995 to 2014 were included. Success was defined as the absence of an additional surgical procedure for AS during 12 months after the last procedure and the absence of a stoma at the end of follow-up. RESULTS: Fifty consecutive patients presenting with AS after CRA (n = 16, 32%), CAA (n = 18, 36%) or IPAA (n = 16, 32%), performed for colorectal cancer (n = 28, 56%), familial adenomatous polyposis (n = 5, 10%), inflammatory bowel disease (n = 8, 16%), diverticulitis (n = 4, 8%), benign colorectal neoplasia (n = 3, 6%) or other (n = 2, 4%) underwent a total of 99 procedures including digital (n = 14, 14%), instrumental (n = 38, 38%) or endoscopic dilatation (n = 5, 5%), transanal AS stricturoplasty (n = 9, 10%), transanal circular stapler resection (n = 11, 11%) or transabdominal redo-anastomosis (n = 22, 22%). Overall the per-procedure success rate was 53% (52/99). Success rates were 36% (5/14) for digital dilatation, 40% (15/38) for instrumental dilatation, 20% (1/5) for endoscopic dilatation, 64% (7/11) for circular stapler resection, 89% (8/9) for stricturoplasty and 73% (16/22) for transabdominal redo-anastomosis. After a mean follow-up of 46 months, 42/50 (84%) patients had treatment that was considered successful. Multivariate analysis identified redo-anastomosis [OR = 5.1 (95% CI: 1.4-18.7), P = 0.003] as the only independent prognostic factor for success. CONCLUSION: AS should be managed according to a step-up strategy. Conservative procedures are associated with acceptable success rates. If these fail, transabdominal redo-anastomosis is associated with the highest probability of success.

Feasibility of Catheter Placement Under Ultrasound Guidance for Progressive Preoperative Pneumoperitoneum for Large Incisional Hernia with Loss of Domain.

INTRODUCTION: Large incisional hernias with loss of domain (LIHLD) of the abdominal wall remain a therapeutic challenge due to the difficulty of replacing the contents of the hernia sac into the peritoneal cavity. Preoperative progressive pneumoperitoneum (PPP) is a valuable option. The purpose of this study was to evaluate the feasibility of peritoneal catheter insertion under ultrasound guidance for PPP and to compare the morbidity and mortality of this new technique to previously used techniques in our department. METHODS: Medical records were reviewed retrospectively from February 1989 to April 2013 in a single institution. Three different techniques of PPP were evaluated: surgical subcutaneous implantable port (SIP), surgical peritoneal dialysis catheter (PDC), and radiologic multipurpose drainage catheter (MDC). Collected data included patients' age, sex, body mass index, medical and surgical history, hernia location, PPP technique, length of hospitalization, volume of air injected, morbidity and mortality linked to PPP, and the procedure of hernia repair. RESULTS: Thirty-seven patients with a mean age of 63.1 years were evaluated. Progressive preoperative pneumoperitoneum was performed using SIP, PDC, and MDC for 14, 11, and 12 patients, respectively. Overall morbidity related to the technique was seen in 36 % of SIP, 27 % of PDC, and 0 % of MDC. One patient from the SIP group died on the 3rd postoperative day due to septic shock following aspiration pneumonia. No postoperative mortality in the other groups was observed. CONCLUSION: The MDC is an interesting modification of the original technique and is a safe procedure. It is a minimally invasive technique with a very low risk of perforation of the viscera. Therefore, the use of a non-absorbable prosthesis with MDC technique can be offered for all patients undergoing PPP without increasing the risk of infection.

Enhancement of the Structure, Thermal, Linear/Nonlinear Optical Properties, and Antibacterial Activity of Poly (vinyl alcohol)/Chitosan/ZnO Nanocomposites for Eco-Friendly Applications.

The preparation of poly (vinyl alcohol)/chitosan/ZnO (PVA/Cs/ZnO) nanocomposite films as bioactive nanocomposites was implemented through an environmentally friendly approach that included mixing, solution pouring, and solvent evaporation. The nanocomposite films were characterized using various techniques such as X-ray diffraction (XRD), Fourier-transform infrared (FT-IR) spectroscopy, differential scanning calorimetry (DSC), thermogravimetric analysis (TGA), and UV-Vis spectroscopy. The XRD study revealed the encapsulation of nanoparticles by the PVA/Cs blend matrix. The DSC results showed that the addition of ZnO NPs increased glass transition and melting temperature values of the PVA/Cs blend. ATR-FTIR spectra detected an irregular shift (either red or blue) in some of the characteristic bands of the PVA/Cs nanocomposite, indicating the existence of intra/intermolecular hydrogen bonding creating an interaction between the OH groups of PVA/Cs and ZnO nanoparticles. A thermogravimetric (TGA) analysis demonstrated that the nanocomposites achieved better thermal resistance than a pure PVA/Cs blend and its thermal stability was enhanced with increasing concentration of ZnO nanoparticles. UV analysis showed that with an increase in the content of ZnO NPs, the optical bandgap of PVA/Cs was decreased from 4.43 eV to 3.55 eV and linear and nonlinear parameters were enhanced. Our optical results suggest the use of PVA/Cs/ZnO nanocomposite films for various optoelectronics applications. PVA/Cs/ZnO nanocomposites exhibited significant antibacterial activity against Gram-positive and Gram-negative bacteria. It was found that nanocomposite samples were more effective against Gram-positive compared to Gram-negative bacteria.

Laparoscopic Colonic Resection Without Urinary Drainage: Is It "Feasible"?

BACKGROUND: Urinary retention following colorectal surgery is a known and costly morbidity. Increasing effort is being made to streamline patient recovery following colon resection, though the ideal timing and duration of urinary catheterization (UC) and its effect on urinary retention (UR) and urinary tract infection (UTI) remain controversial. METHODS: Our program prospectively enrolled patients undergoing elective segmental colon resection through our "fast track" protocol, in which UC is completely avoided unless required for fluid management or to facilitate dissection. Patient demographics and perioperative data including type of analgesia, duration of anesthesia, timing of UC, and rates of perioperative UR and UTI were prospectively recorded. RESULTS: Sixty-five patients met inclusion criteria. Sigmoid colectomy was the most common procedure (76.9 %). The average duration of anesthesia was 274 min, and epidural analgesia was employed in 32 (49.2 %). Twenty-two patients (33.8 %) required temporary perioperative UC. All patients left the operating room without a urinary catheter. Urinary retention occurred in six patients (9.2 %, three with and three without epidural analgesia). One patient who was not catheterized developed a UTI (1.5 %). There was no perioperative mortality. Overall, 39 (60.0 %) patients successfully underwent segmental colon resection and hospital discharge without any UC. CONCLUSIONS: "Fast track" enhanced recovery after elective segmental colon resection without requiring UC is safe and feasible. Epidural analgesia does not mandate the use of UC. In light of the considerable morbidity and cost of UR and UTI, this approach merits further investigation for this patient population.