Bilateral puborectalis interposition repair of rectourethral fistula.

BACKGROUND: Rectourethral fistula is a rare but significant complication that often requires operative intervention. OBJECTIVE: A new perineal approach using the medial aspect of the puborectalis muscles as a double-breasted rotational interposition flap to repair the rectourethral fistula is hereby described. PROCEDURE: With the patient in a modified Lloyd-Davies position, a vertical midline incision from the base of the scrotum to 2 cm anterior to the anal verge is made. The dissection continues along the anterior rectal wall through the Denonvilliers fascia until the rectourethral fistula is reached. The dissection through the fused Denonvilliers fascia continues a further 1 to 2 cm above the fistula. The openings in the rectum and the urethra are then closed vertically (urethra) and horizontally (rectum) with interrupted 3/0 and 4/0 polyglactin sutures. The puborectalis muscles are then mobilized as a 1-cm strip bilaterally and released posteriorly at the level of the anorectum. The 2 strips of the puborectalis muscles are then rotated medially and superiorly along its anterior attachments, forming a double -breasted overlapping flap overlying the fistula openings. The flaps are anchored into the superior and contralateral aspect of the surgical field with the use of 2/0 polyglactin sutures. RESULTS: From November 2011 to December 2012, 4 patients underwent this procedure. No perioperative complications, including those related to the harvesting of the puborectalis muscles, were identified. Subsequent radiological studies confirmed the success of the procedure. After a median follow-up of 8 (6-18) months, 3 patients had their colostomy reversed and remained continent, whereas the last patient had a permanent ileostomy. None of the patients reported any urinary leakage through the perineum. CONCLUSIONS: The double-breasted puborectalis interposition flap is an alternative transperineal procedure in the management of rectourethral fistula. It avoids a laparotomy and is rectum sparing.

Laparoscopic rectal cancer surgery with and without neoadjuvant chemo-irradiation: a comparative study.

OBJECTIVES: To evaluate the perioperative short-term outcomes of laparoscopic rectal cancer surgery in patients after neoadjuvant chemo-irradiation. PATIENTS AND METHODS: This is a comparative cohort study designed to compare the perioperative and short-term outcomes of laparoscopic rectal cancer surgery in patients with and without neoadjuvant therapy. Patients undergoing elective laparoscopic rectal cancer surgery after neoadjuvant chemo-irradiation formed the study group; those receiving surgery without neoadjuvant therapy and in whom the final histology confirmed either transmural or node-positive diseases were selected as controls. RESULTS: Fifty-two patients in the neoadjuvant group were compared with 138 patients in the control group. Both groups were comparable in terms of American Society of Anesthesiologists (ASA) grading and gender distribution. Median operating time was significantly longer in the neoadjuvant group (155 versus 135 mins, p = 0.09, Mann-Whitney U test). No significant difference was observed in terms of blood loss, conversion rates, postoperative morbidity, length of hospital stay or sphincter preservation rates. Overall 5-year survival rates in the two groups remained similar. CONCLUSIONS: Our data confirmed that, aside from a slightly longer operating time, laparoscopic rectal cancer surgery in patients with neoadjuvant chemo-irradiation is safe with no increased morbidity. Based on our experience, patients after neoadjuvant therapy should not be deterred from the minimally invasive approach.

Colonic injury from electric arcing: a significant complication of argon plasma coagulation.

Argon plasma coagulation is increasingly used in endoscopic haemostasis. This case report illustrates the potential for thermal injury at a staple line remote from the area of argon plasma coagulation treatment as a result of electrical arcing. Increasing numbers of colorectal anastomosis and reconstruction procedures are now being performed using stapling techniques and the use of argon plasma coagulation in these patients has become a common situation in clinical practice. Information about this potential danger should be well disseminated to endoscopists and surgeons to avoid preventable complications. The presence of a staple line nearby should be considered a contra-indication for argon plasma coagulation.

Towards painless colonoscopy: a randomized controlled trial on carbon dioxide-insufflating colonoscopy.

BACKGROUND: Carbon dioxide (CO2) insufflation during colonoscopy was reported to reduce pain, but data are limited. The objective of this randomized controlled trial was to assess the effect of CO2 insufflation on pain during and after colonoscopy. METHODS: Patients were randomized into CO2 insufflation (CO2i) or air insufflation (AIRi) groups. Pain during and after the examination were recorded using a visual analogue scale. Other outcomes included the caecal intubation rate, time to reach the caecum and complication. With questionnaire, patients' satisfaction and acceptance of the procedure were assessed. RESULTS: Over a 4-month period, 96 patients were recruited. The caecal intubation rate was 96 and 98% in the CO2i group and the AIRi group, respectively. No complication occurred in the CO2i group whereas one patient from the AIRi group developed late haemorrhage after polypectomy. Patients in the CO2i group had a lower pain score during (P < 0.01) and 30 min after (P = 0.02) the examination. Significantly more patients in the CO2i group reported the examination as painless (visual analogue scale 0) during the procedure (45 vs 14%, P < 0.01) and 30 min after (70 vs 51%, P = 0.04). In both groups, high satisfaction scores were recorded. Most patients (93% for the CO2i group and 98% for the AIRi group) would accept another colonoscopy if indicated. CONCLUSION: Insufflation with CO2 during colonoscopy results in less pain during and after the examination. Because of better tolerance, colonoscopy with CO2 insufflation might gain wide acceptance in the community to be used as a screening tool.

Laparoscopic resection for colorectal cancer in octogenarians: results in a decade.

OBJECTIVES: This study was designed to evaluate the results of laparoscopic resection for colorectal cancer in octogenarians. METHODS: Patients aged 80 years or older who underwent elective laparoscopic resection for colorectal cancer from July 1, 1996 to June 30, 2006 were recruited for analysis, with the following exceptions: 1) patients who did not give informed consent; 2) unfit for operative treatment; 3) presented as surgical emergencies; 4) multiple previous abdominal operations; or 5) locally advanced tumors. Operating time, blood loss, length of hospital stay, mortality and morbidities, including anastomotic dehiscence, pulmonary and wound sepsis, disease recurrence, and patient survival were used to measure outcome. RESULTS: During a ten-year period, laparoscopic colorectal cancer resection was attempted in 101 octogenarians. The median age was 83 (range, 80-95) years and 45 patients were males. The median operating time was 110 (range, 60-245) minutes, with a median blood loss of 50 (range, 0-1,000) ml. Conversion was required in only one case with a leakage rate of 3.3 percent. The overall morbidity and operative mortality rate were 17 and 3 percent, respectively. With a median follow-up of 24 (range, 0-102) months, 22 patients developed recurrence, with 8 of those still surviving. The overall five-year survival is 51 percent. CONCLUSIONS: Our experience confirms that laparoscopic colorectal cancer resection in selected octogenarians is safe and feasible. Aside from the obvious short-term benefits, the long-term oncologic outcomes are favorable.