Omental Infarction: An Underrecognized Cause of Right-Sided Acute Abdominal Pain in Children.

OBJECTIVE: To evaluate the prevalence of omental infarction (OI) in children with suspected appendicitis, the role of ultrasonography (US) in its diagnosis and management and the efficacy of conservative management. METHODS: Consecutive children with suspected acute appendicitis were prospectively enrolled. Ultrasonography was performed at baseline, during follow-up, before the discharge, and at 15-day intervals until US findings of OI disappeared. All children with a diagnosis of OI were treated conservatively. RESULTS: One hundred ninety-nine children (91 male; age range, 3-15 years) were evaluated. Eighty-four patients had acute appendicitis. Omental infarctions were found in 14 children (8 male; mean age, 9.8 ± 2.6 years), with an incidence of 7%. Ultrasonography depicted an echogenic mass consistent with OI in all children. Ultrasonography detected in 8 patients a normal-looking appendix, whereas in other 6 patients, it identified neither appendix nor indirect signs of acute appendicitis. A normal appendix has been detected by US during follow-up in 2 of these 6 patients. During follow-up, US finding of OI disappeared in all cases and no signs of acute appendicitis or other disease occurred. All 14 OIs were treated conservatively, with no reported complications. CONCLUSIONS: Omental infarction is an underestimated cause of abdominal pain in children accounting for 7% of patients with suspected appendicitis. Ultrasonography is a useful method for the diagnoses and to guide clinical management of OI. Conservative therapy is a safe option for the management of OI.

Enteroscopy in children and adults with inflammatory bowel disease.

Inflammatory bowel disease (IBD) includes Crohn's disease (CD), ulcerative colitis and unclassified entities. CD commonly involves the terminal ileum and colon but at the time of diagnosis it can be confined to the small bowel (SB) in about 30% of the patients, especially in the young ones. Management of isolated SB-CD can be challenging and objective evaluation of the SB mucosa is essential in differentiating CD from other enteropathies to achieve therapeutic decisions and to plan the follow-up. The introduction of cross-sectional imaging techniques and capsule endoscopy (CE) have significantly expanded the ability to diagnose SB diseases providing a non-invasive test for the visualization of the entire SB mucosa. The main CE limitations are the low specificity, the lack of therapeutic capabilities and the impossibility to take biopsies. Device assisted enteroscopy (DAE) enables histological confirmation when traditional endoscopy, capsule endoscopy and cross-sectional imaging are inconclusive and also allows therapeutic interventions such as balloon stricture dilation, intralesional steroid injection, capsule retrieval and more recently stent insertion. In the current review we will discuss technical aspect, indications and safety profile of DAE in children and adults with IBD.

Laparoscopic versus open distal gastrectomy for locally advanced gastric cancer in middle-low-volume centers in Western countries: a propensity score matching analysis.

BACKGROUND: Gastrectomy with D2 lymphadenectomy is the standard treatment for patients with resectable gastric cancer. Laparoscopic distal gastrectomy (LDG) is routinely performed for early gastric cancer, and its indications are increasing even for locally advanced gastric cancer. The aim of this study is to compare two middle-low-volume centers in Western countries experience on LDG versus open distal gastrectomy (ODG) for locally advanced gastric cancer in terms of surgical and oncological outcomes. METHODS: We reviewed the data of 123 consecutive patients that underwent LDG and ODG with D2 lymphadenectomy between 2009 and 2014. Among them, 91 were eligible for inclusion (46 LDG and 45 ODG). After propensity score matching analysis, using a 1:1 case-control match, 34 patients were stratified for each group. RESULTS: The mean operative time was significantly longer in the LDG group (257.2 vs. 197.2, p < 0.001). No differences were observed in terms of intraoperative blood loss, average number of lymph nodes removed, and lymph node metastases. The postoperative morbidity was comparable in the two groups. LDG group had a significant faster bowel canalization and soft oral intake (p < 0.001). The 5-year overall and disease-free survival were higher for patients treated by laparoscopy, but the post-hoc subgroups analysis revealed that the advantage of LDG was significant just in N0 and stage IB-II patients, whereas N+ and stage III patient's survival curves were perfectly superimposable. CONCLUSIONS: LDG for locally advanced gastric cancer seems to be feasible and safe with surgical and long-term oncological outcomes comparable with open surgery, even in medium-low-volume centers.

Hydro-MDCT for Gastric Adenocarcinoma Staging. A Comparative Study With Surgical and Histopathological Findings for Selecting Patients for Echo-endoscopy.

BACKGROUND/AIM: In local staging of gastric adenocarcinoma CT is the modality of choice. Less frequently used in a few selected patients is echo-endoscopy. Aim of this study was to evaluate the accuracy of hydro-multidetector-computed tomography (hydro-MDCT) in the evaluation of gastric adenocarcinomas with subsequent surgical and histopathological correlation to select cases for echo-endoscopy. PATIENTS AND METHODS: A total of 65 patients with gastric adenocarcinomas, diagnosed by endoscopy and biopsy, underwent contrast-enhanced hydro-MDCT with subsequent tumor, nodes, metastases (TNM) classification. The distension of the gastric lumen was obtained after the oral administration of 500 ml of water. RESULTS: Hydro-MDCT always detected gastric cancer and in 49/65 patients the assessment of T-parameter was identical to the histopathological results (accuracy: 75%). We found overstaging in 12 and understaging in 4 cases. N-parameter with MDCT was in agreement with histo-pathology in 69%of patients; in metastatic disease hydro-MDCT had an accuracy of 99%. Hydro-MDCT has proven to be a reliable diagnostic technique in evaluating gastric cancer T3-T4 stages in comparison to T1 and T2: in defining T2-stage we found the highest number of errors (37%). CONCLUSION: Hydro-MDCT is a reliable technique in the preoperative staging of gastric adenocarcinoma. Echo-endoscopy could be particularly useful in doubtful cases to evaluate the muscularis propria infiltration (T2 vs. T3) and characterize the peri-gastric lymph nodes.

Intraoperative Treatment of Duct of Luschka during Laparoscopic Cholecystectomy: A Case Report and Revision of Literature.

BACKGROUND: Bile leakage still remains a serious complication during cholecystectomies. In limited cases, this complication may occur from injury of the so-called ducts of Luschka. These rare ducts are usually discovered intraoperatively, and their presence poses the risk of bile injury and clinically significant bile leak. PRESENTATION CASE: We present a unique case of a 59-year-old male patient with acute cholecystitis. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum. We report on the use of endoscopic QuickClip Pro® clips (Olympus Medical Systems Corp., Tokyo, Japan) to avoid further more invasive treatment. DISCUSSION: Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. Many authors have argued the role of relaparoscopy, Diagnosis may be intraoperatively but this option does not seem to occur very often; in fact, there is a lack of data in literature. CONCLUSION: This is the first case report of bile leak from duct of Luschka treated during the cholecystectomies with endoscopic clip.

Value of diffusion-weighted MRI and apparent diffusion coefficient measurements for predicting the response of locally advanced rectal cancer to neoadjuvant chemoradiotherapy.

PURPOSE: The aim of our study was to assess the performance value of magnetic resonance imaging (MRI) in the restaging of locally advanced rectal cancer after neoadjuvant chemoradiotherapy (CRT) and in the identification of good vs. poor responders to neoadjuvant therapy. MATERIALS AND METHODS: A total of 34 patients with locally advanced rectal cancer underwent MRI prior to and after CRT. T stage and tumor regression grade (TRG) on post-CRT MRI was compared with the pathological staging ypT and TRG. Tumor volume and the apparent diffusion coefficient (ADC) were measured using diffusion-weighted imaging (DWI) before and after neoadjuvant CRT; the percentage of tumor volume reduction and the change of ADC (ΔADC) was also calculated. ADC parameters and the percentage of tumor volume reduction were correlated to histopathological results. The diagnostic performance of ADC and volume reduction to assess tumor response was evaluated by calculating the area under the ROC curve and the optimal cut-off values. RESULTS: A significant correlation between the T stage and the TRG defined in DW-MRI after CRT and the ypT and the TRG observed on the surgical specimens was found (p = 0.001; p < 0.001). The mean post-CRT ADC and ΔADC in responder patients was significantly higher compared to non-responder ones (p = 0.001; p = 0.01). Furthermore, the mean post-CRT ADC values were significantly higher in tumors with T-downstage (p = 0.01). CONCLUSION: DW-MRI may have a significant role in the restaging and in the evaluation of post-CRT response of locally advanced rectal cancer. Quantitative analysis of DWI through ADC map may result in a promising noninvasive tool to evaluate the response to therapy.

High-Volume Transanal Surgery with CPH34 HV for the Treatment of III-IV Degree Haemorrhoids: Final Short-Term Results of an Italian Multicenter Clinical Study.

The clinical chart of 621 patients with III-IV haemorrhoids undergoing Stapled Hemorrhoidopexy (SH) with CPH34 HV in 2012-2014 was consecutively reviewed to assess its safety and efficacy after at least 12 months of follow-up. Mean volume of prolapsectomy was significantly higher (13.0 mL; SD, 1.4) in larger prolapse (9.3 mL; SD, 1.2) (p < 0.001). Residual or recurrent haemorrhoids occurred in 11 of 621 patients (1.8%) and in 12 of 581 patients (1.9%), respectively. Relapse was correlated with higher preoperative Constipation Scoring System (CSS) (p = 0.000), Pescatori's degree (p = 0.000), Goligher's grade (p = 0.003), prolapse exceeding half of the length of the Circular Anal Dilator (CAD) (p = 0.000), and higher volume of prolapsectomy (p = 0.000). At regression analysis, only the preoperative CSS, Pescatori's degree, Goligher's grade, and volume of resection were significantly predictive of relapse. A high level of satisfaction (VAS = 8.6; SD, 1.0) coupled with a reduction of 12-month CSS (Δ preoperative CSS/12 mo CSS = 3.4, SD, 2.0; p < 0.001) was observed. The wider prolapsectomy achievable with CPH34 HV determined an overall 3.7% relapse rate in patients with high prevalence of large internal rectal prolapse, coupled with high satisfaction index, significant reduction of CSS, and very low complication rates.

Transanal minimally invasive surgery (TAMIS): new treatment for early rectal cancer and large rectal polyps­experience of an Italian center.

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of rectal tumors that avoids conventional pelvic resectional surgery along with its risks and side effects. Although appealing, the associated cost and complex learning curve limit TEM use by colorectal surgeons. Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to TEM. This platform uses ordinary laparoscopic instruments to achieve high-quality local excision. The aim of the study is to assess reliability of the technique. From July 2012 to August 2013, 15 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, a pneumorectum was established with a laparoscopic device followed by transanal excision with conventional laparoscopic instruments, including graspers, electrocautery, and needle drivers. Patient demographics, operative data, and pathologic data were recorded. Of the 15 patients, 10 had rectal cancers (six T1 lesions and four T2 after preoperative chemoradiotherapy). The remainder of patients had a local excision for voluminous benign rectal adenomas. The median length of the lesions from the anal verge was 7 cm (range, 4 to 20 cm). The median operating time was 86 minutes (range, 33 to 160 minutes). There was no surgical morbidity or mortality. The median postoperative hospital stay was two days (range, 1 to 4 days). TAMIS seems to be a feasible and safe treatment option for early rectal cancer. We believe that this new technique is easy to perform, cost-effective, and less traumatic to the anal sphincter compared with traditional TEM.

Residual Prolapse in Patients with III-IV Degree Haemorrhoids Undergoing Stapled Haemorrhoidopexy with CPH34 HV: Results of an Italian Multicentric Clinical Study.

CPH34 HV, a high volume stapler, was tested in order to assess its safety and efficacy in reducing residual/recurrent haemorrhoids. The clinical charts of 430 patients with third- to fourth-degree haemorrhoids undergoing SH in 2012-2013 were consecutively reviewed, excluding those with obstructed defecation (rectocele >2 cm; Wexner's score >15). Follow-up was scheduled at six and 12 months. Rectal prolapse exceeding more than half of CAD was reported in 341 patients (79.3%); one technical failure was reported (0.2%) without any serious untoward effect; and 1.3 stitch/patient (SD, 1.7) was required to achieve complete haemostasis. Doughnuts volume was higher (13.8 mL; SD, 1.5) in patients with a large rectal prolapse than with smaller one (8.9 mL; SD, 0.7) (P value <0.05). Residual and recurrent haemorrhoids occurred in 8 of 430 patients (1.8%) and 5 of 254 patients (1.9%), respectively. A high index of patient satisfaction (visual analogue scale = 8.9; SD, 0.9) coupled with a persistent reduction of constipation scores (CSS = 5.0, SD, 2.2) was observed. The wider prolapse resection well correlated with a clear-cut reduction of haemorrhoidal relapse, a high index of patient satisfaction, and clinically relevant reduction of constipations scores coupled with satisfactory haemostatic properties of CPH34 HV.

Laparoscopic resection of large gastric GISTs: feasibility and long-term results.

BACKGROUND: Laparoscopy is the procedure of choice for the resection of gastric Gastrointestinal stromal tumors (GISTs) smaller than 2 cm; there is still debate regarding the most appropriate operative approach for larger GISTs. The aims of this study were to evaluate the safety and long-term efficacy of laparoscopic resection of gastric GISTs larger than 2 cm. METHODS: Between 2007 and 2011, we prospectively enrolled all patients affected by gastric GIST larger than 2 cm. Exclusion criteria for the laparoscopic approach were the presence of metastases and the absence of any involvement of the esophago-gastric junction, the pyloric canal, or any adjacent organ. Final diagnosis of GIST was confirmed by histological and immunohistochemical analysis. Follow-up assessment included abdominal CT scans every 6 months for the first 2 years and yearly thereafter. RESULTS: Twenty-four consecutive patients were enrolled. Twenty-one patients (87.5%) were symptomatic. The most common symptoms were gastrointestinal bleeding and abdominal pain. The mean tumor size was 5.51 cm (range 2.5-12.0 cm). GISTs were located in the lesser curvature in five cases (20.8%), in the greater curvature in seven cases (29.1%), in the posterior wall in one case (4.1%), in the anterior wall in eight cases (33.3%), and in the fundus in 3 cases (12.5%). Laparoscopic resection was possible in all cases and took on average of 55 min (range 30-105 min). Median blood loss was 24 ml. No major intraoperative complications were observed. Mortality rate was 0%. Median postoperative stay was 3 days. No patients were lost to follow-up. No recurrences occurred after a median follow-up period of 75 months. CONCLUSION: Although larger randomized controlled trials comparing different surgical strategies for large gastric GISTs are warranted, our study supports the evidence that laparoscopic resection of gastric GISTs is feasible, safe, and effective on long-term clinical outcome even for lesions up to 12 cm.

Long-term results of pilonidal sinus disease with modified primary closure: new technique on 450 patients.

Chronic pilonidal disease is a debilitating condition that typically affects young adults. Controversy still exists regarding the best surgical technique for the treatment of pilonidal disease in terms of minimizing disease recurrence and patient discomfort. The present study analyzes the results of excision with our modified primary closure. This retrospective study involving consecutive patients with pilonidal disease was conducted over a 6-year period. From January 2004 to January 2010, 450 consecutive patients with primary pilonidal sinus disease received this new surgical treatment. Times for complete healing and return to work, the duration of operation and of hospitalization, postoperative pain, time to first mobilization, and postoperative complications were recorded. To evaluate patient comfort, all patients were asked to complete a questionnaire including visual analog scale. The median long-term follow-up was 54 months (range, 24 to 84 months). Four hundred fifty consecutive patients (96 female, 354 male) underwent excision. The median age was 25 years (range, 17 to 43 years). The median follow-up period was 54 months (range, 24 to 84 months). Four hundred twenty completed questionnaires were returned (87% response rate). The median duration of hospital stay was eight hours (range, 7 to 10 hours) No patient reported severe postoperative pain. Primary operative success (complete wound healing without recurrence) was achieved in 98.2 per cent. Two (0.5%) patients had a recurrence. The mean time lost to work/school after modified primary closure was eight days. Excision and primary closure with this new technique is an effective treatment for chronic pilonidal disease. It is associated with low morbidity, early return to work, and excellent cosmetic result and a high degree of patient satisfaction in the long-term follow-up.

Neoadjuvant chemoradiation with concomitant boost radiotherapy associated to capecitabine in rectal cancer patients.

PURPOSE: The primary end-points were complete pathological response and local control. Secondary end-points were survivals, anal sphincter preservation, and toxicity profile. METHODS: Patients with T3/T4 and or N+ rectal cancer (n = 65) were treated with preoperative concomitant boost radiotherapy (55 Gy/25 fractions) associated to concurrent chemotherapy with oral capecitabine. RESULTS: All patients completed the programmed treatment. The complete pathological response was achieved by 17 % of the patients. Anal sphincter preservation surgery was possible for 86 % of the patients with low rectal cancer (≤ 5 cm from the anal verge). The T-stage and N-stage downstaging were achieved by 40 and 58 % of the patients, respectively. Circumferential radial margin was involved (close/positive) in eight patients. After a median follow-up of 26 months, local and distant recurrence occurred in two and 11 patients, respectively. The 3-year overall survival and disease-free survival were 86.8 and 81 %, respectively. Non-hematological ≥ grade 3 toxicities were observed in 15 % of the patients. On univariate analysis N-downstaging and positive circumferential radial margin were significantly associated with worse overall survival (p = 0.003 and p = 0.023, respectively), disease-free survival (p = 0.001 and p = 0.036, respectively), and metastasis-free survival (MFS) (p = 0.001 and p = 0.038, respectively).On multivariate analysis, the N-downstaging were significantly associated with better overall survival (OS) (p = 0.022). CONCLUSIONS: Our data support the efficacy of preoperative treatment for rectal cancer in terms of local outcomes. Radiation treatment intensification may have a biological rationale; longer follow-up is needed.

Laparoscopic total mesorectal excision for ultralow rectal cancer with transanal intersphincteric dissection as a first step: a single-surgeon experience.

Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility of laparoscopic ISR preceded by transanal rectal dissection low rectal cancer. Between December 2009 and June 2011, we performed laparoscopic ISR for 30 patients with very low rectal cancer. Patients received preoperative concurrent chemoradiation (5 days a week for 5 weeks). The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, ISR, transanal coloanal anastomosis with coloplasty and loop ileostomy. Clinical data of 30 patients were analyzed retrospectively. Thirty patients (21 men, nine women) had a median age of 65 years (range, 37 to 75 years), a median body weight of 67 kg (range, 43 to 96 kg), and body mass index of 24 kg/m(2) (range, 19 to 33 kg/m(2)). The distance of the tumor from the anal verge was 5 cm (range, 2 to 11 cm). The operative time was from 240 to 360 minutes, and estimated blood loss was 100 to 520 mL. There were no conversions and no postoperative mortality. This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease while preserving anal function.

Endorectal ultrasonography performance in staging rectal cancer before and after neoadjuvant chemoradiotherapy.

AIM: To evaluate accuracy of endorectal ultrasonography (ERUS) both in staging and restaging rectal cancer after neoadjuvant chemoradiotherapy treatment. METHODS: In a group of 80 patients with rectal cancer, we retrospectively selected 67 patients and divided in two groups: 41 patients affected by a stage I were investigated with a single preoperative endorectal sonography; 26 patients with locally advanced rectal cancer (stage II or more) were restaged after neoadjuvant treatment, which consisted of 5,040 cGy in 28 daily fractions associated with continuous infusion of 5-Fluorouracil. All patients underwent surgery and ERUS findings were subsequently compared with histological findings. RESULTS: Diagnostic accuracy of ERUS in the first group of patients was high: in fact T-staging was accurate in 85% of cases. Results in the second group were significantly less accurate, with a correct T-staging just for 47% of cases. Nodes involvement was correctly evaluated in 86% of cases for the first group and in 63% of cases for the second one. CONCLUSIONS: Endorectal sonography is a valid staging modality for early rectal malignancy. Advanced cancer is treated with neoadjuvant preoperative chemoradiotherapy which is associated with better outcome than postoperative treatment. We found endorectal sonography, based on the layer model of rectal wall, often fails restaging and we think we have to develop new criteria for a correct preoperative assessment after neoadjuvant chemoradiation. KEY WORDS: Endorectal ultrasonography, Neoadjuvant chemoradiotherapy, Rectal cancer, Staging.

Laparoscopic treatment for unsuspected common bile duct stones by transcystic sphincter of Oddi pneumatic balloon dilation and pressure-washing technique.

BACKGROUND: Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure. METHODS: We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008. RESULTS: In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days. CONCLUSION: Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.

Laparoscopic lower anterior rectal resection using a curved stapler: original technique and preliminary experience.

Laparoscopic low anterior rectal resection (LLAR), allowing better visualization and rectal mobilization, can reduce postoperative pain and recovery. A contour curved stapler (CCS) is a very helpful device because of its curved profile that consents better access into the pelvic cavity and allows to perform rectal closure and section in one shot, especially in the presence of a narrow pelvis, complex anatomy, or large tumors. We developed an original technique of laparoscopic rectal resection using CCS. Between 2005 and 2009, in 36 cases, we performed LLAR with a three-trocar technique, starting with mobilization of left colonic flexure followed by the section of inferior mesenteric vessels. The rectum was prepared up to the levator ani with total mesorectal excision. The Lapdisc was inserted trough a suprapubic midline incision, allowing the CCS stapler placement into the pelvic cavity. After the rectal section, the anastomosis was then performed with a circular stapler. Ileostomy was performed if neoadjuvant radiotherapy and chemotherapy have been carried out or if the anastomosis was below 4 cm from the anal verge. Mean operative time was 135 minutes and no intra- or postoperative bleeding occurred. In 27 patients we performed temporary ileostomy. In two cases we observed anastomotic leakage; one of these patients already had ileostomy. No anastomotic stenosis occurred after one-year follow-up. This procedure simplifies the section of the lower rectum, reduces leaking rate resulting from technical difficulties, and does not nullify the benefits of laparoscopy.

Total laparoscopic reversal of Hartmann's procedure.

Hartmann's procedure is still performed in those cases in which colorectal anastomosis might be unsafe. Reversal of Hartmann's procedure (HR) is considered a major surgical procedure with a high morbidity (55 to 60%) and mortality rate (0 to 4%). To decrease these rates, laparoscopic Hartmann's reversal procedure was successfully experienced. We report our totally laparoscopic Hartmann's reversal technique. Between 2004 and 2010 we performed 27 HRs with a totally laparoscopic approach. The efficacy and safety of this technique were demonstrated evaluating the operative data, postoperative complications, and the outcome of the patients. There were no open conversions or major intraoperative complications. Anastomotic leaking occurred in one patient requiring an ileostomy; one patient needed a blood transfusion and one had a nosocomial pneumonia. The mean postoperative hospitalization was 5.7 days. Laparoscopic HR is a feasible and safe procedure and can be considered a valid alternative to open HR.

Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial.

BACKGROUND: Defecatory disorders are very common complications after left hemicolectomy and anterior rectal resection. These disorders seem related primarily to colonic denervation after the resection. To evaluate the real benefits of inferior mesenteric artery (IMA) preservation via laparoscopic left hemicolectomy performed for diverticular disease in terms of reduced colonic denervation and improved postoperative intestinal functions, a randomized, single-blinded (patients) controlled clinical trial was conducted. METHODS: From January 2004 to January 2010, patients with symptomatic diverticular disease and a surgical indication were enrolled in the study and randomly assigned to two treatment groups. The first group underwent laparoscopic left hemicolectomy, which preserved the IMA by sectioning the sigmoid arteries one by one near the colonic wall, In the second group, the IMA was sectioned immediately below the origin of left colic artery. Defecation disorders were assessed by anorectal manometry and by three questionnaires to evaluate constipation, incontinence, and quality of life 6 months after the intervention. RESULTS: A total of 107 patients were included in the study. The 54 patients with preserved IMA showed a statistically lower incidence of defecation disorders such as fragmented evacuations, alternating bowel function, constipation, and minor incontinence, as well as less lifestyle alteration than the 53 patients with the IMA sectioned just below the left colic artery. CONCLUSIONS: This study confirmed that preservation of the IMA should be recommended to reduce the incidence of defecatory disorders after left hemicolectomy for benign disease.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity.

BACKGROUND: Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS: The entire study was conducted at a university hospital. PATIENTS: : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.