The Use of Inlay Bridge of the Posterior Fascia as Adjuvants to a Modified Rives-Stoppa Repair for Difficult Abdominal Wall Hernias.

BACKGROUND: Major abdominal wall defects remain a highly morbid complication. Occasionally a fascial defect is encountered, that despite all surgical efforts, is unable to completely approximate at the midline. Here we describe our method and outcomes of using a bridging mesh when the posterior fascia was unable to be approximated during the repair of large postoperative ventral hernias using the modified Rives-Stoppa technique. METHODS: A retrospective review was conducted looking at all the open abdominal wall hernia repairs between 2014 and 2020. The cohort of patients who had a bridge placed in addition to the traditional open modified Rives-Stoppa repair were used for this study. RESULTS: Nineteen patients had a mesh inlay bridge placed in addition to a modified Rives-Stoppa repair with a sublay (retrorectus) Ultrapro mesh. For the inlay mesh 13 Symbotex composite meshes were placed and 6 Vicryl meshes used. The average surface area of the defect was 358.1 cm^2. The average length of hospitalization was 8.8 days with a range of 3-24 days. During the immediate postoperative course there were 6 minor complications. During the follow-up period there were 2 recurrences. DISCUSSION: The use of inlay mesh bridge as an adjuvant to a modified Rives-Stoppa repair with a sublay ultrapro mesh is an effective technique for difficult abdominal wall repairs where the posterior fascia is unable to be approximated without tension.

Doppler-guided haemorrhoidal artery ligation in patients with Crohn's disease.

AIM: The outcome of Doppler-guided haemorrhoidal artery ligation (DGHAL) was assessed in patients with Crohn's disease (CD) suffering from grade III haemorrhoids. METHOD: A retrospective study was carried out of patients with CD and symptomatic Grade III haemorrhoids treated by DGHAL. Perioperative and follow-up data were retrieved from our database of patients undergoing DGHAL. RESULTS: The study included seven men and six women. The mean age was 34 years old. All had CD without anorectal involvement. The median duration of haemorrhoidal symptoms was 6.3 years. There was no mortality, new incontinence, faecal impaction, urinary retention, abscess formation or persistent pain following the procedure. Mean pain score based on a visual analogue scale (VAS) decreased from 2.4 at 24 h postoperatively to 1.6 on the seventh postoperative day. All patients had completely recovered by the third postoperative day. At 18 months, three (77%) of the patients were asymptomatic and three had recurrent symptoms. CONCLUSION: Doppler-guided haemorrhoidal artery ligation is safe and effective in treating Grade III haemorrhoids in patients with CD without rectal involvement.

Inflammation and colon cancer.

The connection between inflammation and tumorigenesis is well-established and in the last decade has received a great deal of supporting evidence from genetic, pharmacological, and epidemiological data. Inflammatory bowel disease is an important risk factor for the development of colon cancer. Inflammation is also likely to be involved with other forms of sporadic as well as heritable colon cancer. The molecular mechanisms by which inflammation promotes cancer development are still being uncovered and could differ between colitis-associated and other forms of colorectal cancer. Recent work has elucidated the role of distinct immune cells, cytokines, and other immune mediators in virtually all steps of colon tumorigenesis, including initiation, promotion, progression, and metastasis. These mechanisms, as well as new approaches to prevention and therapy, are discussed in this review.

Malignant melanoma and pregnancy: second thoughts.

Malignant melanoma (MM) was considered a hormone-sensitive tumour, and pregnancy was thought to increase its risk and cause faster progression and earlier metastasis. Several controlled studies demonstrated similar survival rates between pregnant and non-pregnant patients and concluded that early reports of advanced MM of pregnancy were probably due to late diagnosis. We retrieved information from our database between 1997 and 2006 on all patients diagnosed as having MM during and up to 6 months after pregnancy (n=11) and compared them to age-matched, non-pregnant, MM patients (n=65, controls) treated by us during that period. The mean Breslow thickness was 4.28mm for the pregnant patients and 1.69mm for the controls (p=0.15). The sentinel nodes were metastatic in five pregnant patients compared to four controls (p<0.0001). Two patients in the pregnancy group and one control died of MM (p=0.0532). Our results indicate a negative effect of pregnancy on the course of MM.

IL-6 and Stat3 are required for survival of intestinal epithelial cells and development of colitis-associated cancer.

Colitis-associated cancer (CAC) is the most serious complication of inflammatory bowel disease. Proinflammatory cytokines have been suggested to regulate preneoplastic growth during CAC tumorigenesis. Interleukin 6 (IL-6) is a multifunctional NF-kappaB-regulated cytokine that acts on epithelial and immune cells. Using genetic tools, we now demonstrate that IL-6 is a critical tumor promoter during early CAC tumorigenesis. In addition to enhancing proliferation of tumor-initiating cells, IL-6 produced by lamina propria myeloid cells protects normal and premalignant intestinal epithelial cells (IECs) from apoptosis. The proliferative and survival effects of IL-6 are largely mediated by the transcription factor Stat3, whose IEC-specific ablation has profound impact on CAC tumorigenesis. Thus, the NF-kappaB-IL-6-Stat3 cascade is an important regulator of the proliferation and survival of tumor-initiating IECs.

Laparoscopic surgery for colorectal polyps.

BACKGROUND: Size, location, and type of colonic polyps may prevent colonoscopic polypectomy. Laparoscopic colectomy may serve as an optimal alternative in these patients. We assessed the perioperative outcome and the risk for cancer in patients operated on laparoscopically for colonic polyps not amenable to colonoscopic resection. METHODS: An evaluation was conducted of our prospective accumulated data of a consecutive series of patients operated on for colonic polyps. RESULTS: Sixty-four patients underwent laparoscopic resection for colonic polyps during a 6-year period. This group comprised 18% of all our laparoscopic colorectal procedures. Forty-six percent were males, mean age was 71. Most of the polyps (66%) were located on the right side. No deaths occurred. Conversion was necessary in 3 patients (4.6%). Significant complications occurred in 3 patients (4.6%). Nine patients (14%) were found to have malignancy. Three of them had lymph-node involvement. No difference existed in polyp size between malignant and nonmalignant lesions. CONCLUSIONS: Laparoscopic colectomy for endoscopic nonresectable colonic polyps is a safe, simple procedure as reflected by the low rate of conversions and complications. However, invasive cancer may be found in the final pathology following surgery. This mandates a strict adherence to surgical oncological principles. Polyp size cannot predict the risk of malignancy.

Learning curve in laparoscopic colorectal surgery: our first 100 patients.

BACKGROUND: Recent data confirming the oncologic safety of laparoscopic colectomy for cancer as well as its potential benefits will likely motivate more surgeons to perform laparoscopic colorectal surgery. OBJECTIVES: To assess factors related to the learning curve of laparoscopic colorectal surgery, such as the number of operations performed, the type of procedures, major complications, and oncologic resections. METHODS: We evaluated the data of our first 100 elective laparoscopic colorectal operations performed during a 2 year period and compared the first 50 cases with the following 50. RESULTS: The mean age of the study population was 66 years and 49% were males. Indications included cancer, polyps, diverticular disease, Crohn's disease, and others, in 50%, 23%, 13%, 7% and 7% respectively. Mean operative time was 170 minutes. One patient died (massive pulmonary embolism). Significant surgical complications occurred in 10 patients (10%). Hospital stay averaged 8 days. Comparison of the first 50 procedures with the next 50 revealed a significant decrease in major surgical complications (20% vs. 0%). Mean operative time decreased from 180 to 160 minutes and hospital stay from 8.6 to 7.2 days. There was no difference in conversion rate and mean number of harvested nodes in both groups. Residents performed 8% of the operations in the first 50 cases compared with 20% in the second 50 cases. Right colectomies had shorter operative times and fewer conversions. CONCLUSIONS: There was a significant decrease in major complications after the first 50 laparoscopic colorectal procedures. Adequate oncologic resections may be achieved early in the learning curve. Right colectomies are less difficult to perform and are recommended as initial procedures.

First 100 cases with Doppler-guided hemorrhoidal artery ligation.

PURPOSE: This study was designed to examine the benefits of a Doppler-guided hemorrhoidal artery ligation technique in terms of surgical outcome, functional recovery, and postoperative pain. METHODS: Using local, regional, or general anesthesia, 100 patients with symptomatic Grades II or III hemorrhoids underwent sonographic identification and suture ligation of six to eight terminal branches of the superior rectal artery above the dentate line. Visual Analog Scales were used for postoperative pain scoring. Surgical and functional outcomes were assessed at 6 weeks and 3, 6, and 12 months after surgery. RESULTS: There were 42 (42 percent) males and 58 (58 percent) females (mean age, 42 years; median duration of symptoms, 6.3 years). The mean operative time was 19 minutes. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only five were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative course. The mean pain score decreased from 2.1 at two hours postoperative to 1.3 on the first postoperative day. All patients had a complete functional recovery by the third postoperative day. Ninety-four patients remained asymptomatic after a mean follow-up of six months: four patients required additional surgical excision, and two required rubber band ligations for persistent bleeding. On follow-up, there was no report of incontinence to gas or feces, fecal impaction, or persistent pain. CONCLUSIONS: Our experience indicates that Doppler-guided hemorrhoidal artery ligation is safe and effective and can be performed as an outpatient procedure with local or regional anesthesia and with minimal postoperative pain and early recovery.

Free perforation in Crohn's disease.

BACKGROUND: Free bowel perforation is one of the indications for emergency surgery in Crohn's disease. It is generally accepted that 1-3% of patients with Crohn's disease will present with a free perforation initially or eventually in their disease course. OBJECTIVES: To evaluate the incidence and treatment results of free perforation in patients with Crohn's disease and, based on our experience, to suggest recommendations. METHODS: Between 1987 and 1996, 160 patients with Crohn's disease were treated in our department and were followed for a mean period of 5 years. RESULTS: Of the 83 patients (52%) requiring surgical intervention, 13 (15.6%) were operated due to free perforation. The mean age of the perforated CD was 33 +/- 12 years and the mean duration of symptoms prior to surgery was 6 years. The location of the free perforation was the terminal ileum in 10 patients, the mid-ileum in 2 patients, and the left colon in 1 patient. Surgical treatment included 10 ileocecectomies, 2 segmental resections of small bowel, and resection of left colon with transverse colostomy and mucus fistula in one patient. There was no operative mortality. Postoperative hospital stay was 21 +/- 12 days (range 8-55 days). All patients were followed for 10-120 months (mean 58.0 +/- 36.7). Six patients (42%) required a second operation during the follow-up period. CONCLUSION: The incidence of free perforation in Crohn's disease in our experience was 15.6%. We raise the question whether surgery should be offered earlier to Crohn's disease patients in order to lower the incidence of free perforation.