Ventral mesh rectopexy versus conventional suture technique: a single-institutional experience.

AIMS: Anterior mesh rectopexy is a novel surgical technique for the treatment of complete rectal prolapse, a common disorder in female elderly patients. Aim of the study was to evaluate functional outcomes after ventral mesh rectopexy and conventional suture rectopexy. PATIENTS AND METHODS: Forty patients have been enrolled in this prospective study. Patients were divided into two groups: 20 patients (group A) had a conventional suture rectopexy with a standard technique and 20 patients (group B) underwent an anterior mesh rectopexy. Each patient had a clinic and defecographic diagnosis of full-thickness rectal prolapse, which was further investigated with manometry and clinical questionnaires (Wexner Constipation and Incontinence Score, Rome III criteria). Postoperative outcomes were evaluated through clinical questionnaires, a rigid rectosigmoidoscopy and a defecography, 1 year after surgery. RESULTS: Preoperative Wexner constipation score was greater than 15 in all the patients (21 in group A and 22 in group B); median postoperative score was 15 in group A and 11 in group B, and the difference was significant. Median preoperative incontinence score was 11 in group A and 12 in group B; median postoperative score was 9 in group A and 6 in group B. Three patients experienced recurrence in group A and only 1 patient in group B. CONCLUSION: Ventral mesh rectopexy is feasible, safe and effective for the treatment of full-thickness rectal prolapse in a well-fit geriatric population. Better functional results have been achieved compared with conventional suture technique with a trend toward a lower recurrence rate.

Conversion during laparoscopic colorectal resections: a complication or a drawback? A systematic review and meta-analysis of short-term outcomes.

PURPOSE: Several studies compared the outcomes of laparoscopically completed colorectal resections (LCR) to those requiring conversion to open surgery (COS). However, a comparative analysis between COS patients and patients undergoing planned open surgery (POS) would be useful to clarify if the conversion can be considered a simple drawback or a complication, being cause of additional postoperative morbidity. The aim of this study is to perform a meta-analysis of current evidences comparing postoperative outcomes of COS patients to POS patients. METHODS: A systematic search of Medline, ISI Web of Knowledge, and Scopus was performed to identify studies reporting short-term outcomes of COS and POS patients. Primary outcomes were 30-day overall morbidity and length of postoperative hospital stay. Data were analyzed with fixed-effect modeling, and sensitivity analyses were performed to test the robustness of the results. RESULTS: Twenty studies involving 30,656 patients undergoing POS and 1935 COS patients were selected. The mean conversion rate was 0.17. Similar 30-day overall morbidity and length of postoperative hospital stay were found in COS and POS patients. Wound infection (OR 1.43, 95 % CI 1.12 to 1.83, p < 0.01) was higher in the COS group. Other results were robust. Outcomes were comparable for patients undergoing resection for different natures of the disease (benign vs. malignant) and at different sites (colon vs. rectum). CONCLUSION: Conversions from laparoscopic to open procedure during colorectal resection are not associated with a poorer postoperative outcome compared to patients undergoing planned open surgery, except for a higher risk of wound infection.

Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study.

BACKGROUND: Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, "learning curve" experience, implementing a well standardized operative technique and recovery protocol. METHODS: The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. RESULTS: Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo-Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. CONCLUSION: Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

Stapled haemorrhoidopexy: correlation among histology, intraoperative morphology and interindividual anatomic variability in muco-haemorrhoidal prolapse.

PURPOUSE: The Authors correlated intraoperative mucohaemorrhoidal prolapse morphology, specimen histology, anal canal length and purse-string height. METHODS: Between September-November 2010, 18 patients (9 grade III; 9 grade IV haemorrhoids) underwent stapled haemorrhoidopexy. Mean age was 54 years (range 38-78).Proctoscopic prolapse morphology, anal canal length, pursestring height and external component were evaluated intraoperatively and specimens sent for histology. RESULTS: Intraoperative findings were as follows: 2/18 patients showed no procidentia, 2/18 'haemorrhoid type' prolapse, 14/18 'rectal type' prolapse. Mean anal canal lenght was 3.5 cm (range 2.5-4.5); mean purse-string height was 4.5 cm from the dentate line (range 3.5-5.5); 10/18 patients carried external component. Histology showed mucosa/submucosa in 4/18 cases, muscolaris propria in 9/18, perivisceral fat in 5/18. No procidentia/'haemorrhoid type' prolapse showed only mucosa/submucosa at histolgy; a 'rectal type' morphology showed at least the muscolaris propria. An anal canal > 3.5 cm related to 'haemorrhoid type' prolapse, a pursestring ≤ 4 cm and mucosa/submucosa at histology. An anal canal ≤ 3.5 cm related to 'rectal type' prolapse, a purse string > 4 cm from dentate line and at least the muscolaris propria. One patient required analgesics for >7 days. At three months, 1/18 patient presented urgency, 2/18 stool clustering. In 1/18 patient a moderate grade of external component persisted. DISCUSSION: A possible correlation among anoscopic phenotype, specimen histology, pursestring height, might exist and influence clinical outcomes. CONCLUSIONS: A positive correlation between specimen thickness, purse-string height and 'rectal type' morphology was found. Patients with higher anal canal showed haemorrhoidal pattern of prolapse, a lower purse-string and mucosa/submucosa at histology.Intraoperative prolapsing tissue morphology could represent a further criteria for surgical decision.

Functional results after TME: J-pouch vs straight coloanal anastomosis and role of neoadjuvant radiochemotherapy.

AIM: Purpose of this study was to evaluate short and long term functional outcomes after TME (total mesorectal excision) for rectal cancer. The role of straight anastomosis or colonic J-pouch reconstruction is investigated, as well as the impact of preoperative chemoradiotherapy is analyzed as a cause of the so called "anterior resection syndrome". METHODS: We enrolled 40 patients (17 male and 23 female), in which a low anterior resection was performed: they were divided in four groups: A1 (Straight and no RCT), A2 (Straight and RCT), B1 (J-pouch and no RCT), B2 (J-pouch and RCT). Follow-up was performed six and twelve months after surgery, through a clinical questionnaire ( to assess: stool frequency, incomplete emptying, the presence of fecal leakage, urgency and incontinence ) and through anorectal manometry ( to assess rest pressure, squeeze pressure, max tolerated volume and compliance). Results were evaluated through T-Student and Chi-Squared test. RESULTS: Six months after surgery, colonic J-pouch offers the best clinical and functional results, in both radiated and not radiated patients (except for incomplete emptying); in the straight group, however, there is an improvement of results after twelve months. Chemoradiation therapy is always associated with worse functional results. DISCUSSION: RCT seems to invalidate J-pouch function in particular, in fact twelve months after surgery the difference between J-Pouch and Straight groups is not statistically different for most of the parameters. CONCLUSION: J-pouch gives a real functional advantage for only six months after surgery, especially in patients treated with neoajuvant chemoradiation therapy.

Intersphinteric resection for rectal cancer: role in fecal continence and Quality of Life.

AIM: Aim of this study is to evaluate the presence of fecal incontince and its impact on life-quality after intersphincteric resection for low rectal cancer. MATERIAL AND METHODS: Twentyeight patients (18 males and 10 female) underwent intersphincteric resection for low rectal cancer between 2006 and 2008. The presence of fecal incontinence was evaluated by Wexner score pre-operatory and 3, 6 and 12 months after ileostomy closure; Quality of Life was evaluated by Fecal Incontinence Quality Of Life (FIQL) score. RESULTS: Wexner score was significatively (p<0.01) higher in the post-operative period (14,07 ± 1.94, 13.36 ± 2.3 and 12.29 ± 2.3 at 3.6 and 12 months) than the pre-operative one (0.72 ± 0.71). Post-operative life-quality specifically related to fecal incontince was worse than in the pre-operative period (FIQL: 10.84 ± 2.52 at 12 months vs 16 preoperative period). DISCUSSION: Wexner score results show a significative worsening in fecal incontinence after intersphincteric resection, even if this condition seems to improve during the follow-up. These results agree with literature. CONCLUSIONS: Intersphincteric resection for low rectal cancer is associated, in the short term (12 months), with a significative state of fecal incontinence. This state has a significative impact on life-quality. However a longer follow-up probably might show an improvement in life-quality parameters.

Prospective study of sexual dysfunction in men with rectal cancer: feasibility and results of nerve sparing surgery.

PURPOSE: Rectal cancer surgery is impaired by a high rate of postoperative sexual dysfunction cause of frequent nerve injuries. The aim of this study was to prospectively evaluate sexual function in a group of male patients after total mesorectal excision (TME) for rectal cancer, using an autonomic nerve sparing technique. METHODS: All patients underwent autonomic nerve preserving TME. Sexual function was assessed using the International Index of Erectile Function standardized questionnaire. All patients were studied preoperatively and at 3, 6, 12, 18, and 24 months after surgery. RESULTS: Fifty-one patients with adenocarcinoma of the rectum were enrolled; after excluding 16 patients not sexually active, nine with T4 stage disease and six with metastatic disease, 20 patients were prospectively evaluated. The preoperative erectile function (EF) domain score of the International Index of Erectile Function was 24.3 (±4.1). The score of the EF domain was 17.6 (±7.5), 19.l9 (±7.2), 20.3 (±7.4), 20.5 (±7.4), and 20.6 (±7.4) at 3, 6, 12, 18, and 24 months after surgery. In the group of patients in which there were no macroscopic damages to the nerves, only two out of 15 (13.3%) developed erectile dysfunction. All five patients in whom incomplete pelvic nerve preservation was necessary developed erectile dysfunction. CONCLUSION: Our data show that nerve sparing technique can reduce the incidence of sexual dysfunction. Unfortunately, the technique is not applicable in every patient. Indications and techniques of autonomic nerve preservation are not standardized. Controlled trials with long-term follow-up seem to be necessary.