Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography.

BACKGROUND: The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC). METHODS: This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates. RESULTS: Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%. CONCLUSIONS: FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.

Indocyanine green fluorescence angiography during low anterior resection for low rectal cancer: results of a comparative cohort study.

BACKGROUND: Anastomotic leak (AL) after low anterior resection (LAR) is associated with increased morbidity, mortality, cost and cancer recurrence rates. The aim of this study was to evaluate the impact of fluorescence angiography (FA) on AL following LAR for low rectal cancer. METHODS: This is a single surgeon retrospective cohort study with a historical, consecutively sampled case matched control group. The institution's prospectively maintained institutional review board (IRB)-approved database was queried for all patients who underwent a laparoscopic LAR for rectal neoplasia with a colorectal or coloanal anastomosis < 5 cm from the anal verge between 2013 and 2016. Patients were divided into two groups: patients in whom FA was employed (study group, 2015-2016) and those patients in whom it was not (control group, 2013-2015). All patients were diverted with a loop ileostomy. The primary outcome measured was the AL rate and the secondary outcome measured was change in surgical plan following FA. RESULTS: Sixty patients were included in the study: 30 patients in the FA group and 30 patients in the control group. Patients' demographics, the use of neoadjuvant chemoradiation, tumor stage, and mean height of anastomosis were comparable between the study groups. FA led to a change in surgical plan in four patients (13.3%) none of who suffered an AL. Two patients in the control group had a clinically and radiologically confirmed AL, whereas there were no leaks in the FA group (6.7% vs. 0%, p = 0.49). CONCLUSIONS: FA changed the surgical plan in 13.3% of LAR's, potentially reducing the incidence of AL in these high-risk patients.

Sacral neuromodulation for the treatment of faecal incontinence following proctectomy.

AIM: This study assessed the effectiveness of sacral neuromodulation (SNM) for faecal incontinence (FI) following proctectomy with colorectal or coloanal anastomosis. METHODS: An Institutional Review Board (IRB)-approved database identified patients treated for FI following proctectomy (SNM-P) for benign or malignant disease, who were matched 1:1 according to preoperative Cleveland Clinic Florida Faecal Incontinence Scores (CCF-FIS) with patients without proctectomy (SNM-NP). Primary outcome was change in CCF-FIS. RESULTS: Twelve patients (seven women) were in the SNM-P group and 12 (all women) were in the SNM-NP group. In the SNM-P group, six patients underwent proctectomy for low rectal cancer and five received neoadjuvant chemoradiation. Five patients had handsewn anastomosis, and one had stapled coloanal anastomosis. One lead explantation occurred after a failed 2-week SNM percutaneous trial. Six patients underwent proctectomy for benign conditions. Within-group analyses revealed significant improvement in CCF-FIS in the SNM-P group (reduction from a score of 18 to a score of 14; P = 0.02), which was more profound for benign disease (reduction from 14.5 to 8.5) than for rectal cancer (reduction from 19.5 to 15). SNM was explanted in 66% and 33% of patients after proctectomy for malignant and benign conditions, respectively. In the SNM-NP group, 41% underwent overlapping sphincteroplasty. One patient received chemoradiation for anal cancer. Within-group analysis for the SNM-NP group showed significant improvement in CCF-FIS (a reduction from 17.5 to 4.0; P = 0.003). There was significant improvement in CCF-FIS in patients without previous proctectomy (mean delta CCF-FIS: 11.1 vs 4.7; P = 0.011). Analysis of covariance (ANCOVA) reaffirmed that controls outperformed proctectomy patients (P = 0.006). CONCLUSION: SNM for FI after proctectomy appears less effective than SNM in patients without proctectomy, with high device explantation rates, particularly after neoadjuvant chemoradiation and proctectomy for low rectal cancer.

Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation.

AIM: Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect. METHOD: Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS). RESULTS: Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06). CONCLUSION: Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

Influence of body posture on defecation: a prospective study of "The Thinker" position.

PURPOSE: We hypothesized that bending the upper body into what we have termed "The Thinker" position facilitates defecation. This study aimed to assess the influence of "The Thinker" position on defecation. METHODS: This is the prospective single-group study. Patients who could not evacuate the paste in normal sitting position on cinedefecography between January and June 2013 were enrolled in this study. Cinedefecography was first performed in the sitting position; if the patient was unable to evacuate the paste, images were obtained in "The Thinker" position. Patients who were able to evacuate the paste were excluded from the study. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining in both positions were measured from the radiographs. RESULTS: Twenty-two patients unable to evacuate the barium paste underwent cinedefecography in "The Thinker" position. Seventeen patients were female, average age of 56 (range 22-76) years. "The Thinker" position had significantly wider ARA than the sitting position (113° vs. 134°, respectively; p = 0.03), larger PPD (7.1 vs. 9.3 cm, respectively; p = 0.02), and longer PRL (12.9 vs. 15.2 cm, respectively; p = 0.005) during straining. Eleven patients could evacuate completely in "The Thinker" position. CONCLUSION: "The Thinker" position seems to be a more efficient method for defecation than the sitting position. This technique may be helpful when retraining patients with constipation.

Prophylactic ureteric catheters in laparoscopic colorectal surgery.

BACKGROUND: The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure. METHODS: Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed. RESULTS: Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group. CONCLUSION: Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Faecal incontinence in male patients.

OBJECTIVE: Data concerning faecal incontinence (FI) in men are lacking. The aim of this study was to evaluate the historical aetiology and contrast aetiologies in younger and older men suffering from FI. METHOD: After institutional review board approval, a retrospective chart review was undertaken of all patients with FI seen between 1999 and 2005. The data of male patients was further analysed to assess the impact of age and historical aetiology on FI. RESULTS: A total of 404 males were included, 203 patients were <70 years of age (group A) and 201 patients were >or=70 years of age (group B). The most common prior diagnosis in group A was perianal sepsis in 23 (11.3%) patients and symptomatic haemorrhoids in 20 (9.9%) patients; in group B it was prostate cancer in 57 (28.4%) patients, symptomatic haemorrhoids in 31 (15.4%) patients and neurological diseases in 18 (9%) patients. The most common prior procedure in group A was restorative proctectomy/proctocolectomy in 32 (15.8%) patients, fistulotomy or haemorrhoidectomy in 21 (10.3%) and 19 (9.4%) patients respectively. In group B, radiation therapy for prostate cancer was utilized in 48 (23.9%) patients and haemorrhoidectomy in 29 (14.4%) patients. Comparing group A and group B relative to diagnosis - perianal sepsis, perineal trauma, congenital disorders, HIV infection and anal cancer were more common in group A, whereas prostate cancer, neurological diseases and colon cancer were significantly more common in group B. CONCLUSION: Prostate cancer, symptomatic haemorrhoids, perianal sepsis, rectal cancer and a history of restorative rectal resection were common associations with FI in men. The aetiologies for FI in men vary with age.

Do elderly patients benefit from laparoscopic colorectal surgery?

BACKGROUND: The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients. AIM: To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP). METHODS: A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age >or= 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality. RESULTS: 641 patients (M/F - 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) - p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3-17) days versus 8.7 (4-22) days in group B (p <0.0001), and LAP: 5.3 (2-19) days versus 6.4 (2-34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003). CONCLUSIONS: Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

Nasogastric tubes and dietary advancement after laparoscopic and open colorectal surgery.

Historically, all patients having abdominal procedures routinely awoke with a nasogastric tube, which remained until the resolution of the postoperative ileus as defined by the passage of flatus or feces per rectum. Dietary advancement was accomplished in a stepwise fashion, starting with clear liquids, progressing to full liquids, and finally a regular diet. Recently, the postoperative nutritional management of elective colorectal surgical patients has undergone several modifications and advancements. With the advent of the laparoscopic technique, attention was focused on the reported benefits of decreased postoperative pain, length of ileus, and consequently faster return to tolerance of diet. Surgeons then began to wonder if these benefits were really unique to laparoscopic surgery, or if laparotomy patients were merely treated differently than laparoscopy patients during the postoperative course. The next logical question was whether, after laparotomy, patients could be treated in the same manner as laparoscopic patients and enjoy the same postoperative benefits. The avoidance of a nasogastric tube and hence the subsequent rapid advancement of diet may shorten the length of hospitalization.