Proctoscopy following transrectal prostate biopsy can control rectal bleeding after prostate biopsy.

OBJECTIVES: Rectal bleeding is a common complication of transrectal ultrasound-guided prostate biopsy (TRPB). Massive rectal bleeding after TRPB can be life threatening. We initiated proctoscopy after TRPB to clarify the incidence of rectal bleeding and evaluated the usefulness of proctoscopy for controlling bleeding after TRPB. MATERIALS: Two hundred and fifty six patients who underwent TRPB were included in the study. TRPB was performed under local anesthesia. Post-biopsy, we performed a proctoscopy to evaluate the degree of rectal bleeding at four levels (G0, no bleeding; G1, traces; G2, venous bleeding requiring hemostasis; and G3, massive venous bleeding or arterial bleeding). Once the bleeding site on the rectal wall was identified, a gauze tampon was placed at the bleeding site and compressed for a few minutes. A second proctoscopy was performed to confirm complete hemostasis, after which the TRPB was terminated. RESULTS: Proctoscopy revealed that the degree of bleeding was G0 in 27 cases, G1 in 104 cases, G2 in 116 cases, and G3 in nine cases. Rectal bleeding that required hemostasis (G2 and G3) was observed in 125 of 256 cases (48.3%). Among the 125 cases, bleeding was stopped by compression in 121 cases; in the remaining four cases, bleeding continued despite compression and was stopped by suturing of the bleeding site. Suturing was performed by urologists, and none of the 256 patients had problematic posterior hemorrhage. CONCLUSIONS: Proctoscopy enables precise and effective pressure hemostasis. Moreover, suturing hemostasis under direct vision can be performed in cases in which pressure hemostasis is difficult. Continued proctoscopy allays urologists' fear of post-TRPB rectal bleeding.

Intraoperative Anastomotic Evaluation Methods: Rigid Proctoscopy Versus Flexible Endoscopy.

INTRODUCTION: Rigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks to determine whether there is an association between the endoscopic modality used to evaluate colorectal anastomoses and the rate of anastomotic leak (AL), organ space infection, and overall infectious complication. METHODS: The 2012-2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing colorectal anastomoses. Anastomotic evaluation method (RP versus FS) was identified by Current Procedural Terminologycoding and used for group classification. Outcomes measured included AL, organ space infections, and overall infection. Multivariable logistic regression analysis for predicting AL was performed. RESULTS: We identified 7100 patients who underwent a colorectal anastomosis with intraoperative endoscopic evaluation. RP was utilized in 3397 (47.8%) and FS in 3703 (52.2%) patients. RP was used more commonly in diverticulitis (44.5% versus 36.2%, P < 0.01), while FS was used more frequently in malignancy (47.5% versus 36.7%, P < 0.01). Anastomotic evaluation with FS was associated with lower rates of organ space infection (3.8% versus 4.8%, P = 0.025) and AL (2.9% versus 3.8%, P = 0.028) compared to RP. On multivariate logistic regression modeling, anastomotic evaluation with RP was associated with a higher risk of AL (odds ratio 1.403, 95% CI 1.028-1.916, P = 0.033) compared to FS. CONCLUSIONS: Compared to FS, rigid proctosigmoidoscopic evaluation of a colorectal anastomosis was associated with an increased rate of AL and organ space infection.

Prophylactic Clipping After Colorectal Endoscopic Resection Prevents Bleeding of Large, Proximal Polyps: Meta-analysis of Randomized Trials.

BACKGROUND & AIMS: The benefits of prophylactic clipping to prevent bleeding after polypectomy are unclear. We conducted an updated meta-analysis of randomized trials to assess the efficacy of clipping in preventing bleeding after polypectomy, overall and according to polyp size and location. METHODS: We searched the MEDLINE/PubMed, Embase, and Scopus databases for randomized trials that compared the effects of clipping vs not clipping to prevent bleeding after polypectomy. We performed a random-effects meta-analysis to generate pooled relative risks (RRs) with 95% CIs. Multilevel random-effects metaregression analysis was used to combine data on bleeding after polypectomy and estimate associations between rates of bleeding and polyp characteristics. RESULTS: We analyzed data from 9 trials, comprising 71897 colorectal lesions (22.5% 20 mm or larger; 49.2% with proximal location). Clipping, compared with no clipping, did not significantly reduce the overall risk of postpolypectomy bleeding (2.2% with clipping vs 3.3% with no clipping; RR, 0.69; 95% confidence interval [CI], 0.45-1.08; P = .072). Clipping significantly reduced risk of bleeding after removal of polyps that were 20 mm or larger (4.3% had bleeding after clipping vs 7.6% had bleeding with no clipping; RR, 0.51; 95% CI, 0.33-0.78; P = .020) or that were in a proximal location (3.0% had bleeding after clipping vs 6.2% had bleeding with no clipping; RR, 0.53; 95% CI, 0.35-0.81; P < .001). In multilevel metaregression analysis that adjusted for polyp size and location, prophylactic clipping was significantly associated with reduced risk of bleeding after removal of large proximal polyps (RR, 0.37; 95% CI, 0.22-0.61; P = .021) but not small proximal lesions (RR, 0.88; 95% CI, 0.48-1.62; P = .581). CONCLUSIONS: In a meta-analysis of randomized trials, we found that routine use of prophylactic clipping does not reduce risk of postpolypectomy bleeding overall. However, clipping appeared to reduce bleeding after removal of large (more than 20 mm) proximal lesions.

Endoloop ligation after endoscopic mucosal resection using a transparent cap: A novel method to treat small rectal carcinoid tumors.

BACKGROUND: Local endoscopic resection is an effective method for the treatment of small rectal carcinoid tumors, but remnant tumor at the margin after resection remains to be an issue. AIM: To evaluate the efficacy and safety of resection of small rectal carcinoid tumors by endoloop ligation after cap-endoscopic mucosal resection (LC-EMR) using a transparent cap. METHODS: Thirty-four patients with rectal carcinoid tumors of less than 10 mm in diameter were treated by LC-EMR (n = 22) or endoscopic submucosal dissection (ESD) (n = 12) between January 2016 and December 2017. Demographic data, complete resection rates, pathologically complete resection rates, operation duration, and postoperative complications were collected. All cases were followed for 6 to 30 mo. RESULTS: A total of 22 LC-EMR cases and 12 ESD cases were enrolled. The average age was 48.18 ± 12.31 and 46.17 ± 12.57 years old, and the tumor size was 7.23 ± 1.63 mm and 7.50 ± 1.38 mm, respectively, for the LC-EMR and ESD groups. Resection time in the ESD group was longer than that in the LC-EMR group (15.67 ± 2.15 min vs 5.91 ± 0.87 min; P < 0.001). All lesions were completely resected at one time. No perforation or delayed bleeding was observed in either group. Pathologically complete resection (P-CR) rate was 86.36% (19/22) and 91.67% (11/12) in the LC-EMR and ESD groups (P = 0.646), respectively. Two of the three cases with a positive margin in the LC-EMR group received transanal endoscopic microsurgery (TEM) and tumor cells were not identified in the postoperative specimens. The other case with a positive margin chose follow-up without further operation. One case with remnant tumor after ESD received further local ligation treatment. Neither local recurrence nor lymph node metastasis was found during the follow-up period. CONCLUSION: LC-EMR appears to be an efficient and simple method for the treatment of small rectal carcinoid tumors, which can effectively avoid margin remnant tumors.

Decrease of Sphincter Preserving Length Lowers the Postoperative Genital Function for Patients With Rectal Cancer.

BACKGROUND AND OBJECTIVE: With the increase in sphincter preserving rate of rectal cancer (RC) cancer, postoperative quality-of-life, such as genital dysfunction, has become a major issue in the patient management. In this study, we proposed a measurement, namely, the sphincter preserving length (SPL), and investigated the relationship between SPL and postoperative genital function and survival in RC patients. METHODS: A total of 536 male patients who had a diagnosis of RC and underwent sphincter preserving rectal resection in the Sixth Affiliated Hospital of Sun Yat-sen University and the First Affiliated Hospital of Sun Yat-sen University between October 1997 and December 2013 were included in our study. SPL was defined as the distance between the lowest edge of the tumor to dentate line. Postoperative genital function was evaluated by erection function and ejaculation function. Five-year survival status was extracted from the hospital database. RESULTS: Larger SPL was significantly associated with poorer postoperative erection and ejaculation function. For a SPL of 7.25 cm, the sensitivity and specificity of the diagnosis of erection dysfunction was 68.6% and 68.8%, respectively. The corresponding sensitivity and specificity for the diagnosis of ejaculation dysfunction was 70.9% and 75.7%, respectively. SPL was also negatively associated with survival rate. Compared with lower anterior resection, patients with lower RC who underwent local resection or draw-out colon-anal anastomosis had better postoperative genital function. CONCLUSIONS: SPL might be a useful measurement to assess the risk of postoperative genital dysfunction and survival status and an indicator for initiation of early preventative treatment in patients with RC.

Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review.

BACKGROUND: The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC®) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety. METHODS: A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated. RESULTS: Eighteen studies (VAAFT-12, FiLaC™-3, OTSC®-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™. CONCLUSIONS: All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.

Incidence and risk factors for rectal pain after laparoscopic rectal cancer surgery.

Objective This study was performed to investigate the incidence of and potential risk factors for rectal pain after laparoscopic rectal cancer surgery. Methods We retrospectively analyzed data from 300 patients who underwent laparoscopic rectal cancer surgery. We assessed the presence of rectal pain and categorized patients into Group N (no rectal pain) or Group P (rectal pain). Results In total, 288 patients were included. Of these patients, 39 (13.5%) reported rectal pain and 14 (4.9%) had rectal pain that persisted for >3 months. Univariate analysis revealed that patients in Group P had more preoperative chemoradiotherapy, more ileostomies, longer operation times, more anastomotic margins of <2 cm from the anal verge, more anastomotic leakage, and longer hospital stays. Multivariate analysis identified an anastomotic margin of <2 cm from the anal verge and a long operation time as risk factors. The presence of diabetes mellitus was a negative predictor of rectal pain. Conclusions In this study, the incidence of rectal pain after laparoscopic rectal cancer surgery was 13.5%. An anastomotic margin of <2 cm from the anal verge and a long operation time were risk factors for rectal pain. The presence of diabetes mellitus was a negative predictor of rectal pain. Thus, the possibility of postoperative rectal pain should be discussed preoperatively with patients with these risk factors.

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.

Visceral obesity, muscle mass and outcome in rectal cancer surgery after neo-adjuvant chemo-radiation.

BACKGROUND: Preoperative chemoradiation has become a routine modality in the treatment of rectal carcinoma that may impair a patients general condition. In these patients, it is important to identify factors that influence postoperative recovery. Visceral obesity(VO) as a metabolic risk factor was studied in rectal cancer patients receiving preoperative chemoradiation. AIM: The impact of VO on post-operative outcome in rectal carcinoma surgery after preoperative chemoradiation was studied. In addition, the effect of chemoradiation on body composition was studied. METHOD: The visceral fat area(VFA), total fat area(TFA) and skeletal muscle area(SMA) were measured on cross-sectional CT-slides in 74 patients who underwent rectal cancer surgery after chemoradiation. CT-scans taken before and after chemoradiation were analysed. Associations between VFA, per- and postoperative complications were studied. A VFA of 100 cm(2) and 130 cm(2) was used to differentiate between non-VO and VO. RESULTS: Using a VO cut-off point of a VFA of 100 cm(2), the VO patients had more per-operative blood loss(471 mL vs 271 mL p = 0.020), a higher complication rate(10% vs 49% p = 0.001), more ileus(2% vs 28% p = 0.027) and a longer length of stay(9.7days vs 13days p = 0.027). When a VFA of 130 cm(2) was used, VO patients showed more complications(17% vs 55%, p = 0.001) and ileus(10% vs 32% p = 0.017). During chemoradiation the SMA increased(Mean difference: 2.2 cm(2) p = 0.024), while the VFA showed no change. CONCLUSION: It appears that VO is associated with co-morbidity and poor outcome in rectal cancer patients. Using different cutoff values for VO different associations with outcome were found. SMA increased during chemoradiation, a phenomenon that remains to be explained.

Endoscopic resection of subtotal or completely circumferential laterally spreading colonic adenomas: technique, caveats, and outcomes.

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) is an established treatment for large (≥ 20 mm) laterally spreading lesions (LSLs). LSLs with complete or subtotal (> 90 %) circumferential extent (C-LSLs) are generally referred for surgery. Data on technique, efficacy, and safety of EMR for these lesions are absent. The aim of this study was to describe the technique and long-term outcomes of EMR for C-LSLs. PATIENTS AND METHODS: Prospective observational study of consecutive patients referred for EMR of LSL at a tertiary care center over 63 months to April 2015. Amongst 979 patients with LSL, 12 patients with C-LSL were seen. RESULTS: All lesions were tubulovillous adenomas with granular 0 - IIa + Is morphology. Median longitudinal extent was 95 mm (range 60 - 160), 58 % were located in the rectum, and 3 lesions (25 %) had complete circumferential involvement. EMR technical success was 100 %. There were no major adverse events. Symptomatic stricturing occurred in 2 cases (17 %) and was treated with endoscopic balloon dilation (median 4 sessions). Median follow up is 13 months. Minor residual adenoma was found in 7 (58 %) at first surveillance colonoscopy and was treated with snare excision. A total of 10 patients have completed a second surveillance colonoscopy with minor residual adenoma found in only 1 case. No patient required surgery or developed cancer in long-term follow-up. CONCLUSIONS: Endoscopic resection of C-LSL is feasible and safe. Minor residual adenoma is common but endoscopically treatable with long-term cure. Symptomatic stricturing amenable to balloon dilation may occur. Empiric surgical referral for C-LSL based on extensive circumferential involvement may be avoided.ClinicalTrials.gov NCT01368289.

Safety of laparoscopic ventral rectopexy in the elderly: results from a nationwide database.

BACKGROUND: Laparoscopic ventral rectopexy is an established procedure in the treatment of posterior pelvic organ prolapse. It is still unclear whether this procedure can be performed safely in the elderly. OBJECTIVE: This study aimed to assess the effects of age on the outcome of laparoscopic ventral rectopexy performed for patients with pelvic organ prolapse. DESIGN: This study was a retrospective cohort analysis with data from a national registry. SETTINGS: The study was conducted in a tertiary care setting. PATIENTS: Patients undergoing laparoscopic ventral rectopexy were identified from discharge summaries. Patients were stratified according to age, including patients <70 (group A) and ≥ 70 (group B) years old. MAIN OUTCOME MEASURES: Variables analyzed included sex, age, diagnosis, associated pelvic organ prolapse, comorbidities, length of stay, complications (Clavien-Dindo scale), and mortality. RESULTS: Among 4303 patients (98.2% women) who underwent a laparoscopic ventral rectopexy, 1263 (29.4%) were >70 years old (mean age, 76.2 ± 5.0 years). Main diagnoses were vaginal vault prolapse (53.0% [group A] vs 47.0% [group B]; p value not significant) and rectal prolapse (17.7 vs 26.8%; p value not significant). Comorbidity was significantly increased in group B (mean length of stay, 5.6 ± 3.6 vs 4.7 ± 1.8 days; p < 0.001) and minor complications (8.4% vs 5.0%; p < 0.001) were significantly increased in group B, whereas major complications were not different (group A, 0.7%; group B, 0.9%; p = 0.40) after univariate analysis. Multivariate analysis found no significant differences between groups. The subgroup analysis of patients >80 years old (n = 299) showed no differences. Each group had 1 postoperative mortality. LIMITATIONS: Limitations of the study include its retrospective design, lack of prestudy power calculation, possible inaccuracy of an administrative database, and selection bias. CONCLUSIONS: Laparoscopic ventral rectopexy appears to be safe in select elderly patients.

Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)--a critical issue.

INTRODUCTION: Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis. PATIENTS AND METHODS: One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed. RESULTS: Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02). CONCLUSION: Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.

Predictive factors for complications in endoscopic resection of large colorectal lesions: a multicenter prospective study.

BACKGROUND AND STUDY AIMS: Conventional endoscopic resection (CER) includes polypectomy and endoscopic mucosal resection. The most common complications related to these techniques are post procedure bleeding and perforation. The aim of this study was to evaluate the outcomes of CER for colorectal neoplasms ≧20 mm and to clarify predictive factors for complications. PATIENTS AND METHODS: We conducted a multicenter prospective study at 18 specialized institutes. From October 2007 to December 2010, 1,029 CERs were performed at participating institutes. We collected the data prospectively and analyzed gender, age, tumor size, gross appearance, mode of resection, etc. RESULTS: The mean size of polyps resected was 26.4 ± 8.6 mm (range 20-120 mm). The final pathology was Vienna classification category 1 or 2 in 24, category 3 in 502, and category 4 or 5 in 503 lesions. Post procedure bleeding and intra procedure perforation occurred, respectively, in 16 (1.6%) and 8 cases (0.78%). The overall complication rate was 2.3%. Risk factors for bleeding in multivariate analysis were only patients under 60 years of age. Risk factors for perforation in multivariate analysis were en bloc resection and Vienna classification category 4-5. The difference of complication rate was not statistically significant regarding gender, size, tumor location, gross appearance, treatment method, and kind of insufflation. CONCLUSION: CER is a safe, efficient, and effective minimally invasive therapy for large colorectal lesions. However, care should be taken for post procedure bleeding in patients under 60 years of age and for perforation in cases of Vienna classification category 4-5 or when an en bloc resection is tried.