Isoperistaltic vs antiperistaltic anastomosis after right hemicolectomy: A comprehensive review.

To optimize the efficiency of ileocolic anastomosis following right hemicolectomy, several variations of the surgical technique have been tested. These include performing the anastomosis intra- or extracorporeally or performing a stapled or hand-sewn anastomosis. Among the least studied is the configuration of the two stumps (i.e., isoperistaltic or antiperistaltic) in the case of a side-to-side anastomosis. The purpose of the present study is to compare the isoperistaltic and antiperistaltic side-to-side anastomotic configuration after right hemicolectomy by reviewing the relevant literature. High-quality literature is scarce, with only three studies directly comparing the two alternatives, and no study has revealed any significant differences in the incidence of anastomosis-related complications such as leakage, stenosis, or bleeding. However, there may be a trend towards an earlier recovery of intestinal function following antiperistaltic anastomosis. Finally, existing data do not identify a certain anastomotic configuration (i.e., isoperistaltic or antiperistaltic) as superior over the other. Thus, the most appropriate approach is to master both anastomotic techniques and select between the two configurations based on each individual case scenario.

The Role of Percutaneous Tibial Nerve Stimulation (PTNS) in Low Anterior Resection Syndrome (LARS): A Systematic Review and Meta-analysis.

PURPOSE: The aim of the present study was to evaluate the pooled efficacy of percutaneous tibial nerve stimulation (PTNS) in patients with low anterior resection syndrome (LARS). MATERIAL AND METHODS: This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The primary endpoint was the pooled effect size of PTNS in LARS score (LARSS). Secondary endpoints included incontinence (Fecal Incontinence Score-FIC, Obstructive Defecation Syndrome-ODS), sexual functionality and quality of life (QoL) questionnaires, and manometric evaluations. Continuous outcomes were reported as weighted mean difference (WMD), with the corresponding 95% confidence interval (95% CI). Quality evaluation was performed via the National Institutes of Health (NIH) quality assessment tool. RESULTS: Overall, 5 studies were included. PTNS resulted to reduced LARSS values (WMD: - 5.68, 95%CI: - 7.73, - 3.63, p < 0.001). A similar effect was noted in St Mark's FIC (p < 0.001) and ODS (p = 0.02) score. An improvement in several QoL scales was found. There was no effect in sexual functionality and manometric measurements. Compared to sham, PTNS significantly improved LARSS. CONCLUSIONS: The application of PTNS in patients with LARS results in an improvement in multiple clinical parameters, including defecation functionality and quality of life. Due to several study limitations, further high quality RCTs are required to delineate the exact efficacy of PTNS.

Quality of life deterioration and colorectal cancer staging in elderly patients. Which comes first?

PURPOSE: Never before the preoperative quality of life (QoL) score of colorectal cancer (CRC) patients was analyzed and linked directly to cancer staging according to pathology in specimens and, thereafter, in patients to estimate long-term prognosis. Our study attempted to give answers to these questions. METHODS: This was a prospective study of 80 elderly patients who underwent major colorectal surgery for cancer in a single University's surgical department conducted between 01/2018 and 12/2018. All patients aged >65 years, diagnosed with a resectable CRC without metastatic disease undergoing an elective surgery were prospectively included. As exclusion criteria were considered age <65 years, an emergency operation, non-resectable tumor, stage IV CRC and American Society of Anesthesiologists (ASA) score IV. All patients were asked to answer a self-administered questionnaire of the validated Greek version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. RESULTS: Comparison of the mean score of EORTC QLQ-C30 showed stage I CRC was 87.62% (11.81%), 77.24% (12.91%) in stage II patients and 78.99% (15.25%) in stage III cancer. The mean difference between the three groups was statistically significant (p=0.002). Moreover, in post-hoc analysis, there was a statistically significant difference in the mean QLQ-C30 score between patients with stage I and stage II cancer (p=0.043) and between patients with stage I and stage III tumor (p=0.01), but this difference was not observed when comparing patients with stage II and III cancer (p=0.319). CONCLUSION: Our study demonstrated a significant association between preoperative QoL and tumor staging as shown in the specimen's examination in elderly patients with CRC. More prospective studies are needed to elucidate how QoL and its fluctuations during the postoperative period can be correlated with long-term survival and disease progression in elderly CRC patients.

The effect of a diverting ileostomy formation on nutritional status and energy intake of patients undergoing colorectal surgery.

BACKGROUND AND AIMS: The effects of ileostomy construction and colonic bypass on the general nutritional status of the patients have not yet received much attention. The aim of the present study was to assess the effect of a diverting ileostomy formation, on the nutritional intake, body composition and nutritional status biochemical markers of patients with a newly formed ileostomy. METHODS: This was an observational study. Patients scheduled for elective rectosigmoid resection at a surgical unit of a public university hospital, were considered for study inclusion. Patients in whom a diverting ileostomy was created were assigned to the ileostomy group (n = 41), and patients who underwent rectosigmoid resection without requiring a diverting ileostomy served as a control group (n = 37). Anthropometric characteristics, body composition, dietary intake and biochemical markers representative of nutritional status were assessed preoperatively and at 40 days postdischarge (NCT02036346). RESULTS: Anthropometric and body composition characteristics (weight, BMI and body fat percentage) significantly declined from 75 to 71.6 kg, 26.9 to 25.6 kg/m2 and 28.6 to 25.6% respectively (p = 0.001 for all) in the ileostomy group, between the preoperative stage and 40 days postdischarge from the hospital. Furthermore, a significant reduction in mean daily energy intake from 1871 to 1713 kcal/day (p = 0.046) was observed in the ileostomy group 40 days after discharge compared to preoperative assessment. No significant changes in the above measured parameters were observed in the non-ileostomy group. CONCLUSION: Diverting ileostomy can have a negative effect on general nutritional status and dietary intake of patients, during the first postoperative period. Nutritional assessment might need to be included in the routine clinical management of this patient category to prevent weight loss and impaired energy intake.

Administration of an Oral Hydration Solution Prevents Electrolyte and Fluid Disturbances and Reduces Readmissions in Patients With a Diverting Ileostomy After Colorectal Surgery: A Prospective, Randomized, Controlled Trial.

BACKGROUND: Patients with a newly formed ileostomy often develop electrolyte abnormalities and dehydration. OBJECTIVE: The study assessed the prophylactic effect of an isotonic hydration solution on dehydration and electrolyte abnormalities in patients with a newly formed ileostomy. DESIGN: This was a prospective, randomized, controlled trial (NCT02036346). SETTINGS: The study was conducted at a single surgical unit of a public university hospital. PATIENTS: Patients scheduled for elective rectosigmoid resection were considered for study inclusion. INTERVENTION: Patients in whom a diverting ileostomy was created were randomly assigned to the intervention group (n = 39), which received an oral isotonic glucose-sodium hydration solution for 40 days postdischarge and the control group (n = 41) which did not receive an intervention. The 2 groups were compared with a group of patients who underwent rectosigmoid resection without diverting ileostomy (n = 37). MAIN OUTCOME MEASURES: Serum electrolyte and renal function markers were assessed preoperatively and at 20 and 40 days postdischarge. RESULTS: At 20 days postdischarge, the serum sodium of the control group appeared lower than the serum sodium of the intervention group and the nonileostomy group (p = 0.007). At the same time point, urea and creatinine levels of the control group were higher than the urea and creatinine levels of the other 2 groups (p = 0.01 and p = 0.02). At 40 days postdischarge, mean sodium and renal function markers improved in the control group, but sodium and creatinine continued to differ in comparison with the intervention and nonileostomy groups (p = 0.01 and p = 0.04). The readmission rate for fluid and electrolyte abnormalities was higher in the control group (24%) than in the other 2 groups, where no rehospitalization for such a reason was required (p = 0.001). LIMITATIONS: The study was limited by its single-center design. CONCLUSION: An oral isotonic drink postdischarge can have a prophylactic effect on patients with a newly formed ileostomy, preventing readmission for fluid and electrolyte abnormalities. See Video Abstract at http://links.lww.com/DCR/A603.

Does Conversion to Open of Laparoscopically Attempted Rectal Cancer Cases Affect Short- and Long-Term Outcomes? A Systematic Review and Meta-Analysis.

INTRODUCTION: Laparoscopy for rectal cancer is a challenge as it presents many technical difficulties and requires high level of expertise. That is the reason for the high conversion rate. Reports on outcomes of converted cases after laparoscopic rectal resection for cancer are conflicting. AIM: The present meta-analysis compares short- and long-term outcomes between converted rectal cancer cases with both open and laparoscopically completed cases. METHOD: All studies reporting on outcomes separately for the converted cases were reviewed systematically. Main outcomes were intraoperative complications, procedure duration, short-term mortality and morbidity, length of stay, local recurrence, number of lymph nodes retrieved, and distant metastases. Quality assessment and data extraction were performed independently by 3 reviewers. RESULTS: Fourteen studies were eligible for analysis, including 10,845 patients. Overall conversion rate was 11.9%. Converted cases had significantly longer duration, hospital stay, and higher rates of wound infection compared with laparoscopic cases. All other outcomes had no difference. When compared with open cases, conversions displayed longer operative times, but there was no other significant difference in the short- or long-term outcomes. CONCLUSION: Converted cases seem to have some short-term unfavorable outcomes. Further retrospective analysis of big registries will be helpful for further investigation of converted cases.

Live birth after laparotomy for concurrent heterotopic pregnancy and appendicitis in a 6 weeks IVF pregnancy.

BACKGROUND: A term delivery after concurrent appendectomy and salpingectomy at 6 weeks in an appendicitis coexisting with a heterotopic pregnancy after in vitro fertilization (IVF) treatment is reported. METHODS: Case report. RESULTS: The patient presented with severe low abdominal pain at 6 weeks of pregnancy after IVF and had explorative laparotomy for appendicitis, during which she had appendectomy and salpingectomy for an undiagnosed concurrent heterotopic pregnancy. The patient delivered a 3,960 g healthy infant at 38 weeks. CONCLUSION: In patients with severe abdominal pain after IVF, appendicitis and heterotopic pregnancy should be included in the differential diagnosis. A dual pathology is possible and when treated appropriately it can result in survival of the precious intrauterine pregnancy. This is the second and earliest ever reported case of that resulted in live birth. It shows that explorative surgery must be performed timely in acute abdomen in pregnancy.