The Extraperitoneal Approach to Left-Sided Colorectal Rectal Resections: EXPERTS Procedure.

BACKGROUND: Current transperitoneal approaches to colorectal resections can be technically challenging, especially in obese patients. The head-down position can lead to rare but serious complications, e.g. compartment syndrome and brachial plexus injuries. OBJECTIVE: The aim of this study was to assess the safety and feasibility of a novel extraperitoneal approach in patients requiring anterior resection. METHODS: The extraperitoneal left-sided approach was performed in the supine position. A 5 cm LIF incision was created into which a Gelpoint port was inserted. The full video of the procedure is embedded in the QR code below. The procedure was performed by three surgeons with experience in minimally invasive surgery. Patients requiring left colonic resections were prospectively selected over a 2-year period. RESULTS: Forty-one patients were prospectively assessed between March 2020 and April 2022; 26 were males, with a median age of 67 (55-88) years. The average body mass index (BMI) was 30 (22-40). 38/41 cases were cancers and three were diverticular diseases; 31 cases had anterior resection and 11 had sigmoid colectomies. Peak airway pressures were significantly less (10 cmH20) in the supine position compared with the head-down position (p < 0.0001). Median time to identify the ureter and gonadal vessels was 23 (3-55) min, and median time to return of bowel function and length of stay was 2 (0-13) and 5 (IQR 3-7) days, respectively. No intraoperative complications or postoperative mortality occurred within 90 days of discharge. Three patients had anastomotic complications, and an R0 resection was achieved in all 38 cancer patients. The median lymph node count was 16. CONCLUSION: Extraperitoneal surgery for left colonic resections is safe and clinically feasible, and allows for early identification of important retroperitoneal structures.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study.

INTRODUCTION: Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position. METHODS: The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure. RESULTS: Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures. CONCLUSIONS: This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Delay in loop ileostomy reversal surgery does not impact upon post-operative clinical outcomes. Complications are associated with an increased loss of microflora in the defunctioned intestine.

Loop ileostomy is a common surgical procedure to allow downstream tissue healing, with the aim of re-joining the bowel approximately 12 months later. The reversal procedure is associated with a substantial morbidity up to 40%. Our previous research demonstrated that defunctioned ileum becomes atrophied, with extensive microbial dysbiosis. This study sought to investigate the potential influence of delaying ileostomy reversal surgery upon both clinical and pathological outcomes. Post-operative clinical data was recorded, including routine blood test results, duration of hospital stay, length of time with stoma and incidence of post-operative complications. We measured ileal fibrosis and atrophy and assessed whether these, or dysbiosis, were impacted by the length of time a stoma was in place, or were linked to clinical outcomes. Associations between clinical data were investigated using scatterplot matrix analysis and t-tests. We found no differences in time between ileostomy formation and reversal in patients experiencing complications vs. individuals with no complications. Furthermore, there were no correlations between days with stoma and pathological measures, such as atrophy or fibrosis, and no ongoing increases in collagen production at the time of reversal surgery. This data suggests that the length of time a stoma is in place does not impact on the likelihood of complications. The incidence of complications is associated with increased loss of microbiota in the defunctioned ileum, but importantly, the decrease in bacteria is not linked to time with stoma. Microbiota diversity in the functional and defunctioned limb correlated within an individual, and was not significantly different between those who experienced complications following surgery vs. those that didn't. Microbiota diversity was also not significantly impacted through delay (>365 days) in stoma reversal. We propose that methods to restore intestinal microbiota numbers, and not necessarily their composition, prior to reversal should be explored to improve the clinical outcomes of ileostomy reversal surgery.

Loop ileostomy-mediated fecal stream diversion is associated with microbial dysbiosis.

Loop ileostomy is an effective procedure to protect downstream intestinal anastomoses. Ileostomy reversal surgery is often performed within 12 months of formation but is associated with substantial morbidity due to severe post-surgical complications. Distal ileum is deprived of enteral nutrition and rendered inactive, often becoming atrophied and fibrotic. This study aimed to investigate the microbial and morphological changes that occur in the defunctioned ileum following loop ileostomy-mediated fecal stream diversion. Functional and defunctioned ileal resection tissue was obtained at the time of loop-ileostomy closure. Intrapatient comparisons, including histological assessment of morphology and epithelial cell proliferation, were performed on paired samples using the functional limb as control. Mucosal-associated microflora was quantified via determination of 16S rRNA gene copy number using qPCR analysis. DGGE with Sanger sequencing and qPCR methods profiled microflora to genus and phylum level, respectively. Reduced villous height and proliferation confirmed atrophy of the defunctioned ileum. DGGE analysis revealed that the microflora within defunctioned ileum is less diverse and convergence between defunctioned microbiota profiles was observed. Candidate Genera, notably Clostridia and Streptococcus, reduced in relative terms in defunctioned ileum. We conclude that Ileostomy-associated nutrient deprivation results in dysbiosis and impaired intestinal renewal in the defunctioned ileum. Altered host-microbial interactions at the mucosal surface likely contribute to the deterioration in homeostasis and thus may underpin numerous postoperative complications. Strategies to sustain the microflora before reanastomosis should be investigated.

Acute endometrial bowel obstruction-A rare indication for colonic stenting.

INTRODUCTION: Pelvic endometriosis is an extremely rare cause of large bowel obstruction and the management can be challenging. Urgent surgery for acute colonic obstruction is known to carry high morbidity and mortality, and operation may be made more difficult in extensive pelvic endometriosis. Less invasive alternatives in the acute situation may need to be considered. PRESENTATION OF CASE: Presented is the case of a 35-year-old lady with obstructive bowel symptoms caused by an endometriotic upper rectal stricture. She was initially treated using radiologically guided stent insertion, as an acute intervention, prior to an elective bowel resection and hysterectomy with bilateral salpingo-oophorectomy. DISCUSSION: Colonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents (SEMS) to treat benign conditions is controversial, however, due to associated long term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial acute treatment with stenting provides the advantage of time to involve the multi-disciplinary team, to medically optimise the patient and to better plan the definitive surgery. CONCLUSION: The use of radiologically guided stents has a place in the treatment of benign recto-sigmoid obstruction due to endometriosis and therefore should be considered as a bridge to further surgical treatment.

Candida: an unexpected cause of the acute abdomen.

The infected intrauterine contraceptive device (IUCD) is a well-described cause of the acute abdomen. However, severe pelvic infection from Candida is an extremely rare complication of the IUCD. We present the first reported description of a Candida-infected IUCD manifesting as an acute abdomen where the degree of infection precluded a conclusive diagnostic workup and necessitated multiple laparotomies. This case highlights the importance for the clinicians to thoroughly exclude such causes of acute sepsis even after exclusion in the presenting history.