Tumor neuroectodérmico maligno del tracto gastrointestinal: a propósito de un caso / Malignant neuroectodermal tumor of the gastrointestinal tract: case report

El tumor neuroectodérmico maligno del tracto gastrointestinal es una neoplasia rara con pocos casos reportados en la literatura, especialmente en América Latina. Descrito por primera vez en 2003, se trata de una entidad sin tratamiento estandarizado y de pobre pronóstico. Se presenta el caso de una paciente de 22 años de edad que acude a la consulta por dolor abdominal, anemia y masa abdominal palpable. Luego de estudios pertinentes se decide la conducta resectiva y el posterior tratamiento oncológico. (AU)

Malignant gastrointestinal neuroectodermal tumor (GNET), formerly known as clear cell sarcoma of the gastrointestinal tract, is an extremely rare tumor of mesenchymal origin, which presents great microscopic and molecular similarity to clear cell sarcoma found in other parts of the body, such as tendons and aponeurosis. It is characterized by its rapid evolution, high recurrence rate and frequent diagnosis as metastatic disease.1,2 (AU)

[Technique of Colon Interposition for Oesophageal Replacement for Oesophageal Cancer]. / Technik der Koloninterposition zum Ösophagusersatz beim Ösophaguskarzinom.

Nowadays, it is only relatively rare and in selected situations that colonic interposition is chosen rather than the stomach as a reconstructive organ for replacing the oesophagus. The colon is a reliable organ for tubular replacement of the oesophagus when the stomach is not available for reconstruction. Colon interposition is a complex and complicated operation. It requires a specific indication and thorough preoperative preparation. From a technical point of view, colon interposition places high demands on the selection and surgical dissection of the vascular supply to the reconstructed organ. The reconstruction route and elevation of the interposition graft to the proximal oesophagus and the need to create 3 or 4 gastrointestinal anastomoses also place significantly higher demands than reconstruction using a gastric tube. Overall, despite the significant surgery-related morbidity, good functional results and a good quality of life can usually be achieved. The surgical technique applied in our own practice is described in detail. An overview from literature on the results of colonic interposition is given, particularly with regard to surgical complications and quality of life after colon interposition.

Ablação térmica para o tratamento do câncer de cólon e reto com metástase hepática irressecável ou ressecável com alto risco cirúrgico / Thermal ablation for colon cancer treatment and challenge with unresectable liver metastasis or resect with high surgical risk

INTRODUÇÃO: As técnicas de ablação são usadas para destruir tumores pequenos (até 4 cm), sem removê-los com cirurgia ou para diminuir seu tamanho possibilitando a cirurgia. A ablação por radiofrequência já é utilizada no SUS para tratamento do carcinoma hepático primário localizado, em estágios I e II. PERGUNTA DE PESQUISA: Para adultos com diagnóstico de câncer de cólon e reto com metástase hepática irressecável ou ressecável com alto risco cirúrgico, o tratamento com ablação térmica (por radiofrequência ou por micro-ondas) é eficaz, efetivo, seguro, custoefetivo e viável economicamente quando comparado ao tratamento com quimioterapia? EVIDÊNCIAS CIENTÍFICAS: Identificaram-se, por busca estruturada, duas revisões sistemáticas e dois estudos primários (duas publicações de um ECR de fase 2, de 2002 a 2007, e um estudo observacional retrospectivo). Não foi identificada evidência para ablação por micro-ondas que atendesse aos critérios de elegibilidade deste PTC. No estudo observa

Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective.

INTRODUCTION: Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception worldwide. The aim of this study is to report our experience and long time consequences and to offer a new medico-legal perspective. MATERIALS AND METHODS: We retrospective review medical charts of patients treated between 2006 and 2021 â€‹b â€‹y the same team directed by the same senior surgeon. We consider major complications and long time sequelaeses as main object for the discussion. Inclusion and exclusion criteria were created. IRB approved the study. After revision a medico-legal perspective was done based on major complications. RESULTS: During the study period 1726 patients, ages between 18 and 71 years old, were treated with 1280 STARR procedures and 446 "Longo" [was stopped on 2012]; all procedures were performed by the senior surgeon and visited by the team at the same control visit at 7days, 30 days and 12 and 18 months after surgery. All patients had 100 â€‹% compliance at 30 days, while 85 â€‹% had long time visit (more than 18 months). During the study period 6 â€‹% (104 subjects) of patients had minor complications while 1 patient (42 â€‹yrs female) reported total fecal incontinence after 18 months (0,05 â€‹%). This patient had mental disorder treated with drugs unknown before surgery and long time mental disorder after surgery. We focused on this last case to discuss long time complication DISCUSSION: This survey reports some interesting clinical data; respect to standard complications minor complications such as pain, bleeding and anal discomfort represent less than 10 â€‹% of procedures that is a good results in this perineal surgery. For those working with rectal mucosal prolapse, obstructed defecation syndrome, rectocele or rectal intussusception is essential to distinguish these diagnosis to have a good counselling with patient before surgery (at least 1 month before). It is essential to check these patients with a close follow-up especially after surgery, to avoid any other mental discomfort related to fecal incontinence; long time fecal incontinence, without anatomical disorders as our case, could be associated and related to drugs consumption or mental disorder, or perineal insensitivity due to surgical procedure. In conclusion it is essential to have good clinical practice to suggest STARR procedure, having idea about different diseases, different surgical approaches and different long time complications.

Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis.

BACKGROUND: The complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts. METHODS: A population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register. RESULTS: During the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery. CONCLUSIONS: The rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis.

BACKGROUND: Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse. METHODS: A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis. RESULTS: Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches. CONCLUSIONS: A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

[Clinicopathological features and prognosis of 47 adults with Hirschsprung's disease and Hirschsprung's disease allied disorders].

Objective: To improve understanding and treatment of adult Hirschsprung's disease (HD) and Hirschsprung's disease allied disorders (HAD) by investigating the clinicopatho- logical features, diagnostic and treatment methods, and prognosis. Methods: This was a retrospective observational study. The study cohort comprised patients aged 18-65 years admitted to the Sixth Hospital of Sun Yat-sen University between January 2007 and December 2022 who were diagnosed with adult HD or HAD by postoperative pathological examination. Those with severe cardiovascular disease, diabetes mellitus, or cirrhosis of the liver were excluded, leaving 47 patients in the study cohort. Emergency open surgery was performed on patients with life-threatening manifestations, whereas those whose condition was stable received conservative treatment to stabilize them, following which they underwent a standard surgical procedure. Surgical procedures performed included the Duhamel procedure, Soave procedure, subtotal colonic resection, total colonic resection, and creation of a palliative stoma. Variables studied included clinicopathological characteristics, treatment modalities, postoperative complications, and long-term anal function. Complications were evaluated in accordance with the Clavien-Dindo criteria, and long-term anal function according to the 2005 Krickenbeck International Classification Criteria. Results: Of the 47 patients, 33 were men and 14 women, with a median age of 29 (18-51) years. HD was diagnosed in 41 (87.2%) patients and HAD in six (12.8%). The commonest initial symptom was dyspareunia (70.2%,33/47), followed by abdominal distension (57.4%, 27/47) and abdominal pain (44.7%,21/47). The detection rates of HD/HAD by barium enema + defecography, anorectal manometry, and preoperative rectal biopsy were 86.8% (33/38), 16/19, and 7/7, respectively. Three (6.4%) patients had discrepant preoperative clinical and postoperative pathological diagnoses. None of the three misdiagnosed patients had undergone preoperative rectal biopsy. Of the 47 study patients, three chose non-surgical treatment and 44 surgical treatment. All surgeries were successfully completed. Postoperative complications occurred in 19 patients (43.2%), including one death case who had undergone emergency surgery. The median duration of follow-up after surgery was 65 (12-180) months. Three patients in the surgical treatment group were lost to follow-up. Of the remaining 41 patients, 36, three, and two had excellent, good, and poor long-term anal function, respectively. The differences in outcomes between the surgical and non-surgical treatment groups (no patients, one, and two with excellent, good, and poor long-term anal function, respectively) (Z=-3.883, P=0.001) were statistically significant. Of the 44 patients who underwent surgical treatment, 41 underwent standard surgeries and three emergency surgeries because their conditions were life-threatening. The difference in complication rate between standard surgery and emergency surgery groups (39.0% [16/41] vs. 3/3, χ2=2.115, P=0.146) was not statistically significant. However, the rate of postoperative Grade III-V complications was lower in the standard surgery group (4.9% [2/41] vs. 2/3, Z=-2.668, P=0.008). Long-term anal function was significantly better in the standard surgery than emergency surgery group (94.7% [36/38] vs. 0/3, Z=-4.935, P=0.001). The 41 standard surgeries included 11 Duhamel's procedures, six Soave's procedures, 19 subtotal colonic resections, three total colonic resections, and two palliative colostomies. The incidence of postoperative complications was significantly superior in the Duhanmels procedures and palliative colostomies group(1/11 and 0/2, P=0.041). Of the 41 patients who underwent standard surgery, 23 underwent open surgery and 18 minimally invasive laparoscopic surgery. The incidence of postoperative Grade III-V complications and long-term anal function were significantly superior in the laparoscopic group than in the open group (all P<0.05). Conclusion: It is easy to misdiagnose adult HD and HAD, surgical treatment is safe and feasible, and its long-term efficacy is good.

Colorectal cancer surgery in octogenarians: real-world long-term results.

AIMS: Colon cancer is the most common intra-abdominal cancer in older people. In the elderly with cancer, clinical decision making is often complicated by the effects of aging. However, as life expectancy continues to rise, more people aged 80 and older will present with colorectal cancer and may need major surgery. METHODS: Between 2000 and 2020 we operated on 352 patients aged 80 and older for colorectal cancer. We reviewed the case-notes of these patients and made a survival analysis for those patients who had a surgical resection of the tumor. RESULTS: In 20 patients a palliative procedure was performed. Three hundred and thirty-two (332) patients had a colorectal cancer resected. Of these, 57 patients died within 90 days postoperatively. Survival analysis was done for 275 patients who were alive longer than 90 days postoperatively. The overall 5-year survival in this group is 41.5%. There was no significant difference in postoperative survival between patients over the age of 85 and patients aged 80-84 at the time of operation. The survival of patients with stage IV colorectal adenocarcinoma is significantly worse than survival in stage I-III patients (Cox-Mantel log-rank test p < 0.001). CONCLUSIONS: After exclusion of the patients in the 90-day mortality group the overall 5-year survival in octogenarians who had a resection of a colorectal cancer was 41.5%. The most difficult problem is to choose the right treatment for the right patient. Optimal surgical and adjuvant treatment should not be denied to these older patients.

[Standardized surgical procedure of conformal sphincter-preservation operation for low rectal cancer (2023 edition)].

Conformal sphincter-preservation operation (CSPO) is considered the effective surgical technique for preserving the sphincter in cases of low rectal cancer. Accurate preoperative diagnosis and staging, reasonable selection of surgical approaches and technique, standardized perioperative management, and postoperative rehabilitation are the keys to ensuring the oncological clearance and functional preservation of CSPO. However, there is currently a lack of standardized surgical procedure for implementing CSPO in China. Therefore, the Colorectal Surgery Group of Surgery Branch of the Chinese Medical Association,along with the Colorectal Cancer Committee of the Chinese Medical Doctor Association and the Anorectal Branch of Chinese Medical Doctor Association, gathered experts in colorectal surgery to discuss and establish this standardized surgical procedure of CSPO. This standard, based on the latest evidence from literature, expert experiences, and China national condition, focuses on the definition, classification, pelvic anatomy, surgical techniques, postoperative complications, and perioperative care of CSPO. It aims to guide the standardized clinical practice of CSPO in China.

Postoperative Outcome of Fistulotomy with Marsupialization in the Surgical Management of Simple Anal Fistula Comparison between Fistulotomy-layopen Procedures.

Assess the wound healing time and early post-operative outcome of fistulotomy with marsupialization, as a surgical treatment of simple fistula-in-ano. This interventional study was performed at the Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Bangladesh from July 2017 to June 2018. Total 30 cases of simple anal fistula were selected according to inclusion criteria. Patients were non-randomly divided in two groups. Fifteen (15) cases were undergone a fistulotomy-lay open (control group) and another 15 cases undergone a fistulotomy with marsupialization (experimental group). The result was tested by t-test, chi-square test. Statistical significance was set at p<0.05. The mean age of the study population was 42.07±13.69 years in fistulotomy-lay open group and 46.00±12.99 years in fistulotomy with marsupialization group. In both group, number of male was higher. Perianal discharge and induration or swelling at perianal skin was most common findings. Mean healing time was earlier in fistulotomy with marsupialization group (16.60±11.15 days) than lay open group (27.07±14.28 days) due to marsupialization technique, the matter of fact that the deep, unepithelized wound has become smaller. No significant difference of postoperative pain, bleeding, wound infection and fecal incontinence in both group. The study shows marsupialization of the wound after fistulotomy for simple fistula in ano results in significantly faster healing in comparison with lay open-fistulotomy, less bleeding without increasing postoperative pain and the infections.

A new technique in the treatment of intestinal malrotation. / Una nueva técnica en el tratamiento de la malrotación intestinal.

INTRODUCTION: Intestinal malrotation is a congenital pathology with potentially catastrophic complications, such as volvulus, whose treatment has barely not changed in nearly 100 years (Ladd's procedure). Dr. Abu-Elmagd recently described a new technique that was applied in one of our patients. CLINICAL CASE: 12-year-old boy who had undergone Ladd's procedure as a result of intestinal volvulus secondary to malrotation when he was 2 days old. He had subocclusion and eventually obstruction, with intestinal volvulus compatible imaging. Intraoperative findings: duodenal subocclusion, volvulus and lymphangiectasias. Kareem's procedure: bowel positioning in normal rotation, duodenopexy (duodenal C posterior to the mesenteric vessels), formation of neo-Treitz, and fixation of the cecum, the ascending colon, and the mesenteric root. The patient was discharged on postoperative day 6 and remains asymptomatic after 1 year of follow-up. DISCUSSION: Kareem's procedure is a safe and effective malrotation repair technique. It can replace Ladd's procedure as it reduces the risk of re-volvulation and improves digestive symptoms.

INTRODUCCION: La malrotación intestinal es una patología congénita con complicaciones potencialmente catastróficas, destacando el vólvulo, cuyo tratamiento no ha variado significativamente en casi 100 años (procedimiento de Ladd). Recientemente el Dr. Abu-Elmagd describió una técnica que hemos aplicado en un paciente. CASO CLINICO: Varón de 12 años, intervenido con 2 días de vida por vólvulo intestinal secundario a malrotación realizándose procedimiento de Ladd. Presenta cuadros suboclusivos y finalmente obstructivo con imágenes compatibles con vólvulo intestinal. Hallazgos intraoperatorios: suboclusión duodenal, vólvulo y linfangiectasias. Procedimiento de Kareem: posicionando intestino en normorotación, duodenopexia (C duodenal posterior a vasos mesentéricos), formación de neoTreitz, fijación de ciego, colon ascendente y raíz mesentérica. Alta hospitalaria al 6º día postoperatorio, asintomático en 1 año de seguimiento. COMENTARIOS: El procedimiento de Kareem es una técnica segura y efectiva que corrige la malrotación, pudiendo reemplazar al procedimiento de Ladd al disminuir el riesgo de revolvulación y mejorar síntomas digestivos.

Prognostic indicators for survival in surgically managed small intestinal obstruction in pet rabbits: 141 presentations (2011-2021).

OBJECTIVE: To determine prognostic relevance of various patient factors and intraoperative variables associated with surgical management of small intestinal obstruction in pet rabbits. ANIMALS: 114 pet rabbits with 141 presentations of small intestinal obstruction treated surgically between June 2011 and December 2021. METHODS: In a retrospective observational study design, medical records were reviewed for rabbits with small intestinal obstruction that had undergone surgical intervention. Data were collected on variables of interest and outcome (survival to hospital discharge). Univariable and multivariable logistic regression analyses were performed to identify variables associated with survival. RESULTS: Overall survival was 75.2% (106/141). Specifically, 95.7% (22/23) of presentations involving rabbits < 25 months survived. The odds of survival on univariable modeling were significantly lower in presentations of rabbits > 72 months compared with those < 25 months (OR, 0.05; 95% CI, 0.01 to 0.40; P = .005). Rectal temperature, clinicopathologic findings, etiology of obstruction, presence of full-thickness gastrointestinal wall injury, and previous small intestinal obstruction surgery did not show significant effects on survival. In a multivariable model that controlled for plasma potassium and calculated plasma osmolarity and tonicity, the odds of survival in presentations of rabbits > 72 months were 95% lower than those < 25 months (OR, 0.05; 95% CI, 0.01 to 0.50; P = .012). CLINICAL RELEVANCE: Surgical intervention should be considered a suitable treatment option for small intestinal obstruction in rabbits < 72 months and carried a good prognosis. The most common etiology was consistent with a compressed hair pellet, and extraluminal digital manipulation into the cecum was a successful surgical technique in most presentations.

Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery. METHODS: A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis. RESULTS: A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal. CONCLUSION: ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.

Malrotación intestinal en el adulto: cirugía de Ladd laparoscópica / Intestinal Malrotation in Adults: laparoscopic Ladd's Surgery

Las malrotaciones por bandas de Ladd son un subtipo de anormalidades de la embriogénesis consistentes en prolongaciones fibrosas, producto de una fijación anómala del mesenterio. Se extienden desde el ciego mal rotado hacia el retroperitoneo, pudiendo producir compresión extrínseca del duodeno. En el 90% de los casos la presentación clínica tiene lugar dentro del primer año de vida como un cuadro agudo, en forma de oclusión duodenal o vólvulo de intestino delgado con la consecuente isquemia de este o hernia interna. En la edad adulta, las formas de presentación son menos específicas. Los métodos de referencia ("gold standard") utilizados para el diagnóstico son la seriada gastroduodenal y la tomografía computarizada. El tratamiento quirúrgico consiste en la cirugía de Ladd, cuyo abordaje convencional fue descripto en 1936 por William Ladd. Presentamos el caso de un paciente adulto con un cuadro oclusivo, causado por dicha anomalía, diagnosticado de forma oportuna y resuelto de manera segura por vía laparoscópica. (AU)

Ladd's band malrotations are a subtype of abnormalities of embryogenesis consisting of fibrous extensions, product of abnormal fixation of the mesentery, that goes from the poorly rotated cecum towards the retroperitoneum, which can cause extrinsic compression of the duodenum. In 90% of cases, the clinical presentation takes place within the first year of life, as an acute condition, like duodenal occlusion or small bowel volvulus with its consequent ischemia or internal hernia. In adulthood, the forms of presentation are less specific. The gold standard methods used for diagnosis are gastroduodenal series and computed tomography. Surgical treatment consists of Ladd's surgery, whose conventional approach was described in 1936 by William Ladd. We present ta case of an adult patient with an occlusive presentation, given by this anomaly, diagnosed in a timely manner and safely resolved by laparoscopic approach. (AU)

Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study.

BACKGROUND: Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids. OBJECTIVE: This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. DESIGN: Multicenter retrospective study. SETTINGS: Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study. PATIENTS: Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period. MAIN OUTCOME MEASURES: The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up. RESULTS: Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device. LIMITATIONS: The retrospective design and the self-reported nature of data from different centers. CONCLUSIONS: Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).

[Chinese expert consensus on intersphincteric resection for low rectal cancer (2023 edition)].

Intersphincteric resection (ISR) is the ultimate sphincter-preserving surgical technique for low rectal cancer. Accurate preoperative diagnosis and staging, appropriate selection of surgical approaches and technique, standardized perioperative management, and postoperative rehabilitation are the keys to ensuring the oncological effect and functional preservation of ISR. To date, there is still a lack of standardized guidance on the clinical implementation of ISR in China. Therefore, based on the latest evidence from literature, expert experience, and the intervention situation in China, the Chinese Society of Colorectal Surgery, Chinese Society of Surgery, Chinese Medical Association organized domestic experts in colorectal surgery to discuss and produce "Chinese expert consensus on intersphincteric resection for low rectal cancer (2023 edition)". This consensus focuses on definition, classification, related pelvic anatomy, operational techniques, postoperative complications, and long-term oncological and functional outcomes, and aims to guide the standardized clinical practice of ISR in the operation of low rectal cancer in China.

[Techniques and classification of intersphincteric resection for ultra-low rectal cancer].

ISR is the most widely used anal-preserving operation for ultra-low rectal cancer. It can be divided into total ISR, subtotal ISR and partial ISR according to the resection range of internal sphincter. The advantage of ISR is that it can preserve the sphincter while ensuring the safety of oncology for ultra-low rectal cancer, representing the state of the art. However, it still needs to face the problem that the quality of life will decline due to poor postoperative anal function. The conformal sphincter-preserving operation (CSPO) is a functional anal-preserving surgery improved on the basis of ISR. It is superior to ISR in the postoperative anal function and patients' quality of life. So it can be a new choice for ultra-low rectal cancer.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision.

OBJECTIVES: the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). METHODS: we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. RESULTS: sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). CONCLUSION: rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

Robotic-assisted proctosigmoidectomy for Hirschsprung's disease: A multicenter prospective study.

BACKGROUND: Robotic surgery is a cutting-edge minimally invasive technique that overcomes many shortcomings of laparoscopic techniques, yet few studies have evaluated the use of robotic surgery to treat Hirschsprung's disease (HSCR). AIM: To analyze the feasibility and medium-term outcomes of robotic-assisted proctosigmoidectomy (RAPS) with sphincter- and nerve-sparing surgery in HSCR patients. METHODS: From July 2015 to January 2022, 156 rectosigmoid HSCR patients were enrolled in this multicenter prospective study. Their sphincters and nerves were spared by dissecting the rectum completely from the pelvic cavity outside the longitudinal muscle of the rectum and then performing transanal Soave pull-through procedures. Surgical outcomes and continence function were analyzed. RESULTS: No conversions or intraoperative complications occurred. The median age at surgery was 9.50 months, and the length of the removed bowel was 15.50 ± 5.23 cm. The total operation time, console time, and anal traction time were 155.22 ± 16.77, 58.01 ± 7.71, and 45.28 ± 8.15 min. There were 25 complications within 30 d and 48 post-30-d complications. For children aged ≥ 4 years, the bowel function score (BFS) was 17.32 ± 2.63, and 90.91% of patients showed moderate-to-good bowel function. The postoperative fecal continence (POFC) score was 10.95 ± 1.04 at 4 years of age, 11.48 ± 0.72 at 5 years of age, and 11.94 ± 0.81 at 6 years of age, showing a promising annual trend. There were no significant differences in postoperative complications, BFS, and POFC scores related to age at surgery being ≤ 3 mo or > 3 mo. CONCLUSION: RAPS is a safe and effective alternative for treating HSCR in children of all ages; it offers the advantage of further minimizing damage to sphincters and perirectal nerves and thus providing better continence function.