Laparoscopic Ladd's procedure: a case report and review of the literature on patient selection for an appropriate surgical approach.

Intestinal malrotation is a rare condition which is managed surgically with the Ladd's procedure. We report a case of an adult male presenting with symptomatic intestinal malrotation which was successfully treated with a laparoscopic Ladd's procedure. While traditionally performed with a laparotomy, the case highlights the emerging evidence in the literature supporting the laparoscopic approach and explores factors affecting patient selection for an appropriate surgical approach.

A Cross-Sectional Study of Sub-Basal Corneal Nerve Reduction Following Neurotoxic Chemotherapy.

Purpose: Sub-basal corneal nerves have been shown to change during neurotoxic chemotherapy treatment. This cross-sectional study investigated corneal nerve morphology in patients who have completed neurotoxic chemotherapy well after treatment cessation and its association with peripheral nerve function. Methods: Central corneal nerve fiber length (CNFL) and inferior whorl length (IWL), average nerve fiber length (ANFL), corneal nerve fiber density (CNFD) and corneal nerve branch density (CNBD), and nerve fiber area (CNFA) were examined using in vivo corneal confocal microscopy in patients with cancer who had completed treatment with either paclitaxel or oxaliplatin between 3 and 24 months prior to assessment in comparison with 2 separate groups of healthy controls. Neurological assessments were conducted including clinician- and patient-reported outcomes, and neurological grading scales. Results: Both paclitaxel- (n = 40) and oxaliplatin-treated (n = 30) groups had reduced IWL and ANFL compared to the respective healthy control groups (n = 15 in each group) (paclitaxel: IWL = P = 0.02, ANFL = P = 0.009; and oxaliplatin: IWL = P = 0.008, ANFL P = 0.02). CNFL and CNFD reduction were observed only in the paclitaxel-treated group compared with healthy controls (P = 0.008 and P = 0.02, respectively), whereas CNFA was reduced in the oxaliplatin-treated group (P = 0.04). IWL reduction correlated with worse fine hand dexterity in chemotherapy-treated patients (r = -0.33, P = 0.007). Conclusions: There is evidence of corneal nerve loss in patients with cancer who have been treated with paclitaxel and oxaliplatin well after treatment cessation associated with worse upper limb function. Translational Relevance: Sub-basal corneal nerve reduction is evident even after cessation of neurotoxic treatment. In vivo corneal confocal microscopy may be useful in the monitoring of nerve function in patients receiving chemotherapy.

Retrospective analysis of a Bi-National Colorectal Cancer Audit to characterize stage II colon cancer patients who were offered adjuvant chemotherapy.

BACKGROUND: Adjuvant chemotherapy for stage II colon cancer is a controversial area with treatment often reserved for patients with high-risk clinicopathological features. The aim of this study was to characterize which patients with stage II disease were offered adjuvant chemotherapy in an Australian and New Zealand setting. METHODS: Data was retrospectively collected from the prospectively maintained Bi-National Colorectal Cancer Audit. Data from all patients with their first episode of stage II colon cancer from January 2007 to January 2019 were included. RESULTS: A total of 3763 patients were identified in the Bi-National Colorectal Cancer Audit database with stage II colon cancer, of which 715 were offered chemotherapy (19%). Patients were at significant greater odds of being offered chemotherapy for stage II disease if they were <55 years old, from an urban area, discussed in a multidisciplinary team (MDT) meeting, had a greater operative urgency, a lower American Society of Anesthesiologists score, had a T4 tumour or had less than 12 lymph nodes harvested. CONCLUSION: In Australia and New Zealand the appropriate patients with high-risk features are more likely to be offered chemotherapy in line with current guideline recommendations; however, this may not be the case for regional patients. A large proportion of patients were not discussed at MDT meeting- given the decision to provide adjuvant chemotherapy for stage II disease remains a controversial area, and the likely small survival benefit offered by adjuvant chemotherapy, appropriate patient selection is critical and best discussed in an MDT setting.

Does indocyanine green improve the evaluation of perfusion during laparoscopic colorectal surgery with extracorporeal anastomosis?

BACKGROUND: There has been recent interest in indocyanine green (ICG) to assess anastomotic perfusion in colorectal surgery. We describe our experience using ICG when performing laparoscopic segmental colorectal resections with extracorporeal anastomotic technique and a highly standardized approach for clinically assessing blood flow. METHODS: We recruited 20 consecutive patients to undergo segmental laparoscopic resection and determined an appropriate point to transect mesentery proximally confirming pulsatile arterial flow at this level. Once confirmed, we did a further perfusion study using ICG to ascertain if this would change intraoperative decision-making. RESULTS: Twenty segmental colonic resections were assessed in nine female and 11 male patients aged 26-91 years. ICG administration was safe with no adverse outcomes documented. ICG demonstrated anastomotic perfusion in all cases. We observed no cases wherewith pulsatile blood flow at the cut edge of the mesentery, ICG showed inadequate perfusion at this level. We did find in 25% of cases ICG showed perfusion beyond the cut edge of the mesentery to a distance of up to 2.5 cm. CONCLUSION: ICG perfusion is safe and straightforward to carry out. However, when pulsatile arterial bleeding is demonstrated clinically it does not add anything to assessment of perfusion in our study. Furthermore, in 25% of cases perfusion can be demonstrated beyond the cut edge of the mesentery up to a distance of 2.5 cm. This raises the possibility that an organ well perfused with ICG may have less than ideal blood flow when assessing for this with a view to constructing an anastomosis.

Randomized controlled trial of probiotics after colonoscopy.

BACKGROUND: Up to 20% of patients have ongoing abdominal symptoms at day 2 and beyond following colonoscopy. It was hypothesized that some of these symptoms are related to alterations in gut microbiota secondary to bowel preparation and would improve with probiotics compared with placebo. METHODS: Patients were given either a probiotic or placebo capsule in the days following colonoscopy. Colonoscopy was performed with air insufflation. The probiotic capsule contained the strains Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07. Patients recorded their symptoms at 1 h, 1, 2, 4, 7 and 14 days post colonoscopy and returned results once their symptoms had resolved. The primary outcomes used were the length of days to resolution of bloating, abdominal pain and altered bowel function post colonoscopy. RESULTS: A total of 320 patients were randomized. After loss to follow-up and withdrawal, 133 patients were analysed in the probiotic group and 126 in the placebo group. Patients having probiotic had a lower number of pain days following colonoscopy, 1.99 versus 2.78 days (P < 0.033). There was no significant difference in bloating or return to normal bowel habit days (P = 0.139 and 0.265 respectively). Subgroup analysis revealed that patients with pre-existing abdominal pain benefited from probiotics in number of pain days, 2.16 versus 4.08 (P = 0.0498). CONCLUSION: Our study has shown a significant reduction in the duration of pain days post colonoscopy in patients taking probiotic compared with placebo. No significant effect was seen in terms of return to normal bowel function or bloating post colonoscopy.

Transanal minimally invasive surgery: an initial experience.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) is a novel approach used for the resection of rectal lesions. The purpose of this study was to review our initial experience with TAMIS. METHODS: Between March 2012 and May 2012, we collected clinical data on patients who underwent the TAMIS procedure. This included patient demographics, tumour characteristics, operative technique, histological results and post-operative outcomes. RESULTS: Three patients successfully underwent TAMIS resection of rectal lesions. All tumours were tubulovillous adenomas with high-grade dysplasia, with one also having a small focus of adenocarcinoma. Clear margins were achieved in all cases. One case was complicated by a post-operative bleed, requiring a return to theatre. CONCLUSIONS: TAMIS is a feasible and cost-effective alternative to transanal endoscopic microsurgery for resection of rectal lesions. It may have a shorter learning curve, especially for laparoscopic surgeons already proficient in single-port procedures.

Complex anal fistulas: plug or flap?

BACKGROUND: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. METHODS: A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. RESULTS: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. CONCLUSIONS: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.

Open surgical treatment of aneurysmal sac expansion following endovascular abdominal aneurysm repair: solution for an unresolved clinical dilemma.

The advantages of endovascular aneurysm repair (EVAR) are probably related to the avoidance of the three major physiological insults associated with open abdominal aortic aneurysm (AAA) repair: laparotomy, aortic cross-clamping and ischemia reperfusion injury. Continuing aneurysm expansion indicates a failure to exclude the AAA from the circulation. We describe our experience with open surgery of post-EVAR sac expansion. A consecutive series of 68 EVAR patients was followed up. Endovascular and minimally invasive procedures were the initial treatment option. Failure of these attempts to curtail AAA sac expansion or type 2 large endoleaks (EL) resulted in opening of the aneurysm sac. The procedure includes positioning of a deflated occlusion balloon proximal to the stent graft (SG). Laparotomy with opening of the eneurysm sac was then performed. The thrombus was removed and backbleeding vessels oversewn. The aneurysm sac was then plicated over the SG. Four patients (5.9%) were diagnosed as having either persistent large type 2 EL or sac enlargement. In all patients the procedure was accomplished successfully. One patient died from acute myocardial infarction perioperatively. Three patients recovered uneventfully and follow-up computed tomography confirmed the absence of endoleak and a disappearance of the AAA. We believe that whenever EVAR fails to exclude the aneurysm from the circulation, open exploration without graft replacement should be considered.

Stent grafts for thoracic aortic pathology: single-center experience in Western Australia.

The purpose of this article is to report a single-center experience in treating thoracic aortic pathology with stent grafts. This is a retrospective review of cases done within a period of 30 months. Between January 2002 and May 2004, 12 patients were treated in our institution with thoracic stent grafts (n = 12) for various clinical conditions. There were seven men and five women. Three patients required emergency treatment (n = 3), two for aortic transection and one for iatrogenic injury during lung biopsy. Others were treated electively (n = 9). All patients were high risk for open surgery. There was one perioperative death, with a patient with multiple trauma succumbing to head injury 4 weeks after stent graft insertion. There was no incidence of paraplegia. Three patients underwent bypass surgery in the neck to achieve an adequate proximal seal zone prior to stent grafting. One patient with an aneurysm of the descending thoracic aorta required an extension limb below the original graft for an increase in sac size, possibly owing to endotension. Renal failure occurred in one patient and resolved without dialysis. One patient died 18 months after her procedure, possibly owing to aneurysm expansion. Stent grafts are a viable alternative to open surgery for thoracic aortic pathology in high-risk individuals. Visceral and spinal cord ischemia is less prevalent with stent grafts compared with open surgery. The short-term results are promising. Long-term follow-up is awaited. Stent grafts might have greater impact in the thoracic aorta than the abdominal aorta for which they were initially developed.