Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection.

OBJECTIVE: To describe the management of recurrent bowel endometriosis after previous colorectal resection. DESIGN: Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. SETTING: A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. INTERVENTION: Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. CONCLUSION: Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

Caracterización del tratamiento con plasma rico en plaquetas y leucocitos en la fisura anal secundaria / Characterization of the Treatment with Platelet-Rich Plasma and Leukocytes against Secondary Anal Fissure

Introducción: Las enfermedades benignas de recto son muy frecuentes en la práctica médica habitual en todos los niveles de atención de salud. Dentro de estos procesos se reconoce que la fisura anal es uno de los más comunes. Objetivo: Caracterizar a los pacientes tratados con plasma rico en plaquetas y leucocitos por fisura anal secundaria en la provincia Camagüey en el período comprendido entre septiembre del 2020 y septiembre del 2022. Métodos: Se realizó un estudio cuasiexperimental, cuyo universo lo conformaron los pacientes con el diagnóstico de fisura anal secundaria que asistieron a la consulta de Coloproctología del Hospital Provincial Docente Oncológico María Curie. Se estableció una muestra no probabilística a criterio de los autores conformada por 132 pacientes adultos, quienes recibieron tratamiento con plasma rico en plaquetas y leucocitos por fisura anal secundaria en la provincia Camagüey. Resultados: Con respecto al sexo y a la edad, se observó una mayor frecuencia del grupo de 40 a 49 años y predominó el sexo femenino. El síntoma de mayor frecuencia fue el dolor, mientras que en la etiología prevaleció la proctitis facticia. En la mayoría de los casos estudiados la fisura anal cicatrizó en menos de 15 días y en cuanto a la evaluación final del tratamiento solo la minoría empeoró. Conclusiones: La caracterización de la muestra en estudio permite afirmar que el tratamiento con plasma rico en plaquetas y leucocitos tiene beneficios para los pacientes con fistulas perianales y su calidad de vida(AU)

Introduction: Benign rectal diseases are very frequent in routine medical practice at all levels of health care. Among these processes, anal fissure is recognized as one of the most common. Objective: To characterize patients treated with platelet-rich plasma and leukocytes for secondary anal fissure in Camagüey Province between September 2020 and September 2022. Methods: A quasiexperimental study was carried out, whose universe was made up of patients with the diagnosis of secondary anal fissure who attended the coloproctology office at Hospital Provincial Docente Oncológico María Curie. A nonprobabilistic sample was established according to the authors' criterions, made up of 132 adult patients who received treatment with platelet-rich plasma and leukocytes for secondary anal fissure in Camagüey Province. Results: Regarding sex and age, a higher frequency was observed in the group 40 to 49 years old and the female sex was predominant. The most frequent symptom was pain, while the prevailing etiology was factitious proctitis. In most of the cases under study, the anal fissure healed in less than 15 days and, regarding the final assessment of the treatment, only the minority worsened. Conclusions: The characterization of the sample under study allows to affirm that treatment with platelet-rich plasma and leukocytes has benefits for patients with perianal fistulas and their quality of life(AU)

Complex perirectal abscess of urethral origin.

A 50-year-old male, with a medical history of Lynch syndrome and transurethral-resection (TUR) secondary to multifocal bladder tumour (pT1-high grade) with normal subsequent follow-ups, consulted for anal pain, rectal tenesmus and fever for 3 weeks. On examination, he presented perianal oedema and, on digital rectal examination, a right lateral orifice was palpable at 6cm from the anal margin. CT scan revealed a defect-in-continuity in the right rectal wall which communicated with bilateral perirectal collections extending towards the puborectalis-levator ani. On the right side, it extended towards the ischiorectal fossa and, on the left side it continued with another collection that displaced the corpus cavernosum. Urgent transanal debridement of abscess with biopsy and cultures was performed. Subsequent evolution was torpid. The clinical history was reviewed, as the patient had undergone repeated bladder catheterizations after TUR and BCG therapy one year before. Abdominal tomography with urethral contrast and cystourethrography were performed, which confirmed the presence of a fistula in the bulbomembranous urethra that communicated with the perirectal abscesses. Cultures and biopsies were negative for mycobacteria and malignancy was ruled out. A new surgical exploration was carried out, enlarging the transanal drainage orifice, making a temporary intestinal stoma and bladder catheterization. After eighteen weeks, the healing of the fistula was verified through of a new cystourethrography. Reconstruction of the intestinal transit has now been scheduled, after radiologically and endoscopically verifying the closure of the rectal orifice.

Low anterior resection syndrome (LARS) after sphincter-sparing rectal cancer surgery. Incidence and risk factors.

BACKGROUNDS: Low anterior resection syndrome (LARS) was defined with symptoms such as frequency, incontinence, urgency, and constipation in patients who underwent Sphincter-Sparing Rectum Surgery (SSRC). In this study, LARS rates and risk factors of the patients who underwent SSRC were Investigated. MATERIAL METHOD: The medical records of patients with SSRC at general surgery department were examined retrospectively. Clinical characteristics, neo/adjuvant chemo-radiotherapies, distal resection levels, open/laparoscopic procedures, postoperative complications, and pathological outcomes were recorded. LARS scoring system defined by Emmertsen and Laurberg was used to calculate LARS scores. RESULTS: The number of eligible patients was 129. The rectal resection was performed by either low anterior resection (LAR) or very low anterior resection (VLAR). VLAR was used to specify that had anastomosis <5cm to the anal verge. The median follow-up time was 12 (1-30) months. LARS were detected in 60 (%47) patients. LARS rates were significantly higher in the patients underwent VLAR (n: 35 9% vs. 48%<0,001). In univariate analysis, the level of distal resection, open surgeries, neoadjuvant RT, and diversion with temporary stoma were significantly different in LARS group. However, in multivariate analysis, distal resection level was the only significant risk factor for LARS. CONCLUSION: Low anterior resection syndrome (LARS) was frequently seen in patients who underwent sphincter-sparing rectum surgery (SSRS). It was detected that distal resection levels were the most important risk factor for the development of LARS. This result showed that LARS should not be disregarded in patients underwent SSRS. KEY WORDS: Bowel Disfunction, Cancer, Incontinence, LARS, Rectum.

Solitary Rectal Ulcer Syndrome: A Rare and Often Misdiagnosed Cause of Rectal Bleeding in Children.

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign rectal disorder. Typically, young adults are affected and it is rare in children. Straining during defecation, self-induced trauma and paradoxical contraction of puborectalis muscle are the major contributing factors of this condition. Clinical features of SRUS are rectal bleeding, mucorrhoea, excessive straining during defecation, tenesmus, feeling of incomplete defecation and constipation. A complete and thorough history is most important for diagnosis of SRUS. Rectal bleeding may be misinterpreted as originating from an anal fissure caused by constipation or as other causes of rectal bleeding such as a juvenile polyp. The best and most accurate diagnostic method of SRUS is rectal biopsy. The major histological feature of SRUS is fibromuscular obliteration of the lamina propria. Avoiding straining, regular toilet habit, use of bulk laxatives, steroid and sucralfate enemas are the mainstay of treatment. Biofeedback mechanism is another treatment option. Because the clinical presentation varies, the diagnosis requires a high index of suspicion for both the clinician and the pathologist.

Solitary rectal ulcer transformation to cap polyposis in a 15-year-old child.

BACKGROUND: Cap polyposis (CP) is a benign, non-malignant inflammatory disease that affects the rectum. It usually occurs during the 5th decade of life, but children could also be affected. Its specific pathology is unknown. Due to the clinical, endoscopic, and histologic similarities with other disorders such as inflammatory bowel disease, a thorough histologic evaluation is critical to avoid unnecessary interventions. This study presents a 15-year-old child with a previously reported case of solitary rectal ulcer (SRU) that developed into CP determined by colonoscopy and histologic findings. CASE PRESENTATION: A 15-year-old boy who was previously diagnosed with SRU presented to our office with rectal bleeding, mucoid discharge, and abdominal pain. Additional colonoscopy evaluation revealed multiple polyposes varying in size and shape limited to the rectum. Histologic examination revealed a characteristic cap of granulation tissue covering tortuous nondysplastic crypts in the inflamed stroma, indicating that SRU had transformed into CP. Based on the assessments, we planned to perform endoscopic mucosal resection of the lesions in multiple sessions. CONCLUSIONS: Despite the rarity of CP, the transformation from SRU may be one of its etiologies. Thus, thorough serial histologic evaluation is critical in children with rectal bleeding to avoid unnecessary or harmful interventions.

Rare case of an 83-year-old woman with transrectal small bowel evisceration caused by spontaneous rectal perforation.

Spontaneous rectal perforation with transanal small intestinal evisceration is a rare condition. We report the case of an 83-year-old woman with a rectal perforation and transanal prolapse of small intestine through the rectal opening who was treated with transanal reposition under general anaesthesia and open Hartmann's procedure. As part of the Hartmann's procedure, segmental resection of the perforated colon was performed. This case illustrates that spontaneous rectal perforation is a severe surgical emergency, which needs immediate reposition and resection of the perforated rectum.

Thoracolumbar epidural stimulation effects on bladder and bowel function in uninjured and chronic transected anesthetized rats.

Pre-clinical studies have shown that spinal cord epidural stimulation (scES) at the level of pelvic and pudendal nerve inputs/outputs (L5-S1) alters storage and/or emptying functions of both the bladder and bowel. The current mapping experiments were conducted to investigate scES efficacy at the level of hypogastric nerve inputs/outputs (T13-L2) in male and female rats under urethane anesthesia. As found with L5-S1 scES, T13-L2 scES at select frequencies and intensities of stimulation produced an increase in inter-contraction interval (ICI) in non-injured female rats but a short-latency void in chronic T9 transected rats, as well as reduced rectal activity in all groups. However, the detrusor pressure during the lengthened ICI (i.e., urinary hold) remained at a low pressure and was not elevated as seen with L5-S1 scES, an effect that's critical for translation to the clinic as high fill pressures can damage the kidneys. Furthermore, T13-L2 scES was shown to stimulate voiding post-transection by increasing bladder activity while also directly inhibiting the external urethral sphincter, a pattern necessary to overcome detrusor-sphincter dyssynergia. Additionally, select scES parameters at T13-L2 also increased distal colon activity in all groups. Together, the current findings suggest that optimization of scES for bladder and bowel will likely require multiple electrode cohorts at different locations that target circuitries coordinating sympathetic, parasympathetic and somatic outputs.