Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids: Long-term Outcomes From the THDLIGA Randomized Controlled Trial

BACKGROUND

Both transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy are safe for grade III to IV hemorrhoid treatment. Whether one of them is superior regarding long-term results remains unclear.

OBJECTIVE

To compare long-term results after transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy.

DESIGN

Multicenter randomized controlled trial.

SETTINGS

This study was conducted at 6 centers.

PATIENTS

Patients ≥18 years of age with grade III to IV hemorrhoids were included in the study.

INTERVENTIONS

Patients were randomly assigned to transanal hemorrhoidal dearterialization (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41).

MAIN OUTCOME MEASURES

The primary outcome was hemorrhoid symptom recurrence assessed by a specific questionnaire 2 years postoperatively. Secondary outcomes included long-term complications, reoperations, fecal continence, and patient satisfaction and quality of life.

RESULTS

Five of the 80 patients included in the study were lost to follow-up. Thirty-six patients randomly assigned to transanal hemorrhoidal dearterialization and 39 patients randomly assigned to vessel-sealing device hemorrhoidectomy were included in the long-term analysis. The differences between mean baseline and mean 2-year score in the 2 groups were similar (-11.0, SD 3.8 vs -12.5, SD 3.6; p = 0.080). Three patients in the transanal hemorrhoidal dearterialization group underwent supplementary procedures for hemorrhoid symptoms, compared with none in the vessel-sealing device hemorrhoidectomy group ( p = 0.106). Four patients in the vessel-sealing hemorrhoidectomy group and none in the transanal hemorrhoidal dearterialization group experienced chronic opened wound ( p = 0.116).

LIMITATIONS

Lack of stratification for hemorrhoid grade and power calculation based on the main outcome trial but not on the end point of this long-term study.

CONCLUSIONS

Transanal hemorrhoidal dearterialization with mucopexy is associated with hemorrhoid symptom recurrence similar to vessel-sealing device hemorrhoidectomy at 2 years. See Video Abstract at http://links.lww.com/DCR/B933 .

REGISTRATION

Clinicaltrials.gov ; ID: NCT02654249.

DESARTERIALIZACIN HEMORROIDAL TRANSANAL CON MUCOPEXIA VERSUS HEMORROIDECTOMA CON DISPOSITIVO DE SELLADO DE VASOS PARA HEMORROIDES DE GRADO IIIIV RESULTADOS A LARGO PLAZO DEL ENSAYO CLNICO ALEATORIZADO THDLIGARCT

ANTECEDENTES:Tanto la desarterialización hemorroidal transanal como la hemorroidectomía con dispositivo de sellado de vasos son seguras y bien toleradas para el tratamiento de las hemorroides de grado III-IV. La primera se asocia con una necesidad más breve de analgesia posoperatoria que la hemorroidectomía con dispositivo de sellado de vasos. No está claro si uno de ellos es superior con respecto a los resultados a largo plazo.OBJETIVO:El objetivo fue comparar los resultados a largo plazo después de la desarterialización hemorroidal transanal y la hemorroidectomía con dispositivo de sellado de vasos.DISEÑO:Se realizó un ensayo clínico aleatorizado multicéntrico.AJUSTE:Este estudio se realizó en 6 centros.PACIENTES:Se incluyeron en el estudio pacientes de ≥18 años con hemorroides de grado III-IV.INTERVENCIONES:Los pacientes fueron asignados al azar a desarterialización hemorroidal transanal (n = 39) o hemorroidectomía con dispositivo de sellado de vasos (n = 41).PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia de los síntomas de hemorroides evaluada mediante un cuestionario específico 2 años después de la operación. Los resultados secundarios incluyeron complicaciones a largo plazo, reoperaciones, continencia fecal, satisfacción del paciente y calidad de vida.RESULTADOS:Cinco de los 80 pacientes incluidos en el estudio se perdieron durante el seguimiento. En el análisis a largo plazo se incluyeron 36 pacientes aleatorizados a desarterialización hemorroidal transanal y 39 aleatorizados a hemorroidectomía con dispositivo de sellado de vasos. Las diferencias entre la puntuación inicial media y la puntuación media a los 2 años en los dos grupos fueron similares (-11,0, DE 3,8 frente a -12,5, DE 3,6; p = 0,080). Tres pacientes en el grupo de desarterialización hemorroidal transanal se sometieron a procedimientos complementarios por síntomas de hemorroides, en comparación con ninguno en el grupo de hemorroidectomía con dispositivo de sellado de vasos (p = 0,106). Cuatro pacientes en el grupo de hemorroidectomía con sellado de vasos y ninguno en el grupo de desarterialización hemorroidal transanal experimentaron herida abierta crónica (p = 0,116). No se encontraron diferencias en cuanto a continencia fecal (p = 0,657), satisfacción del paciente (p = 0,483) y calidad de vida.LIMITACIONES:No hay estratificación para el grado de hemorroides ni el cálculo del poder basado en el resultado principal del ensayo, pero no en el criterio de valoración de este estudio a largo plazo.CONCLUSIONES:La desarterialización hemorroidal transanal con mucopexia se asocia con una recurrencia de síntomas de hemorroides similar a la hemorroidectomía con dispositivo de sellado de vasos a los dos años. See Video Abstract at http://links.lww.com/DCR/B933 . (Traducción- Dr. Francisco M. Abarca-Rendon )REGISTRO DE PRUEBA:Clinicaltrials.gov (NCT02654249).

Prognostic Value of the Circumferential Resection Margin After Curative Surgery for Rectal Cancer: A Multicenter Propensity Score-Matched Analysis

BACKGROUND

Recently, positive circumferential resection margin has been found to be an indicator of advanced disease with a high risk of distant recurrence rather than local recurrence.

OBJECTIVE

The study aimed to analyze the prognostic impact of the circumferential resection margin on long-term oncological outcomes in patients with rectal cancer.

DESIGN

This was a multicenter, propensity score-matched (2:1) analysis comparing the positive and negative circumferential resection margins.

SETTINGS

The study was conducted at 5 high-volume centers in Spain.

PATIENTS

Patients who underwent total mesorectal excision with curative intent for middle-low rectal cancer between 2006 and 2014 were included.

MAIN OUTCOME MEASURES

The main outcomes were local recurrence, distant recurrence, overall survival, and disease-free survival.

RESULTS

The unmatched initial cohort consisted of 1599 patients, of whom 4.9% had a positive circumferential resection margin. After matching, 234 patients were included (156 with a negative circumferential margin and 78 with a positive circumferential margin). The median follow-up period was 52.5 (22.0-69.5) months. Local recurrence was significantly higher in patients with a positive circumferential margin (33.3% vs 11.5%; p < 0.001). Distant recurrence was similar in both groups (46.2% vs 42.3%; p = 0.651). There were no statistically significant differences in 5-year overall survival (48.6% vs 43.6%; p = 0.14). Disease-free survival was lower in patients with a positive circumferential margin (36.1% vs 52.3%; p = 0.026).

LIMITATIONS

This study was limited by its retrospective design. The different neoadjuvant treatment options were not included in the propensity score.

CONCLUSIONS

The positive circumferential resection margin was associated with a higher local recurrence rate and worse disease-free survival in comparison with the negative circumferential resection margin. However, the positive circumferential resection margin was not a prognostic indicator of distant recurrence and overall survival. See Video Abstract at http://links.lww.com/DCR/B950 .

VALOR PRONSTICO DEL MARGEN DE RESECCIN CIRCUNFERENCIAL DESPUS DE LA CIRUGA CURATIVA PARA EL CNCER DE RECTO UN ANLISIS MULTICNTRICO EMPAREJADO POR PUNTAJE DE PROPENSIN

ANTECEDENTES:En los últimos años, se ha encontrado que el margen de resección circunferencial positivo es un indicador de enfermedad avanzada con alto riesgo de recurrencia a distancia más que de recurrencia local.OBJETIVO:El objetivo fue analizar el impacto pronóstico del margen de resección circunferencial sobre la recidiva local, a distancia y las tasas de supervivencia en pacientes con cáncer de recto.DISEÑO:Este fue un análisis multicéntrico emparejado por puntaje de propensión 2: 1 que comparó el margen de resección circunferencial positivo y negativo.AJUSTES:El estudio se realizó en 5 centros Españoles de alto volumen.PACIENTES:Se incluyeron pacientes sometidos a escisión total de mesorrecto con intención curativa por cáncer de recto medio-bajo entre 2006-2014. Las características clínicas e histológicas se utilizaron para el emparejamiento.PRINCIPALES MEDIDAS DE RESULTADO:Los resultadoes principales fueron la recurrencia local, la recurrencia a distancia, la supervivencia global y libre de enfermedad.RESULTADOS:La cohorte inicial no emparejada consistió en 1599 pacientes; El 4,9% tuvo un margen de resección circunferencial positivo. Tras el emparejamiento se incluyeron 234 pacientes (156 con margen circunferencial negativo y 78 con margen circunferencial positivo). La mediana del período de seguimiento fue de 52,5 meses (22,0-69,5). La recurrencia local fue significativamente mayor en pacientes con margen circunferencial positivo, 33,3% vs 11,5% [HR 3,2; IC 95%: 1,83-5,43; p < 0,001]. La recidiva a distancia fue similar en ambos grupos (46,2 % frente a 42,3 %) [HR 1,09, IC 95 %: 0,78-1,90; p = 0,651]. No hubo diferencias significativas en la supervivencia global a 5 años (48,6 % frente a 43,6 %) [HR 1,09, IC 95 %: 0,92-1,78; p = 0,14]; La supervivencia libre de enfermedad fue menor en pacientes con margen circunferencial positivo, 36,1% vs 52,3% [HR 1,5; IC 95%: 1,05-2,06; p = 0,026].LIMITACIONES:Este estudio estuvo limitado por el diseño retrospectivo. Las diferentes opciones de tratamientos neoadyuvantes no se han incluido en la puntuación de propensión.CONCLUSIONES:El margen de resección circunferencial positivo se asocia con una mayor tasa de recurrencia local y peor supervivencia libre de enfermedad en comparación con el margen de resección circunferencial negativo. Sin embargo, el margen de resección circunferencial positivo no fue un indicador pronóstico de recidiva a distancia ni de supervivencia global. Consulte el Video del Resumen en http://links.lww.com/DCR/B950 . (Traducción- Dr. Yesenia Rojas-Khalil ).

Benchmarks in colorectal surgery: multinational study to define quality thresholds in high and low anterior resection

BACKGROUND

Benchmark comparisons in surgery allow identification of gaps in the quality of care provided. The aim of this study was to determine quality thresholds for high (HAR) and low (LAR) anterior resections in colorectal cancer surgery by applying the concept of benchmarking.

METHODS

This 5-year multinational retrospective study included patients who underwent anterior resection for cancer in 19 high-volume centres on five continents. Benchmarks were defined for 11 relevant postoperative variables at discharge, 3 months, and 6 months (for LAR). Benchmarks were calculated for two separate cohorts: patients without (ideal) and those with (non-ideal) outcome-relevant co-morbidities. Benchmark cut-offs were defined as the 75th percentile of each centre's median value.

RESULTS

A total of 3903 patients who underwent HAR and 3726 who had LAR for cancer were analysed. After 3 months' follow-up, the mortality benchmark in HAR for ideal and non-ideal patients was 0.0 versus 3.0 per cent, and in LAR it was 0.0 versus 2.2 per cent. Benchmark results for anastomotic leakage were 5.0 versus 6.9 per cent for HAR, and 13.6 versus 11.8 per cent for LAR. The overall morbidity benchmark in HAR was a Comprehensive Complication Index (CCI®) score of 8.6 versus 14.7, and that for LAR was CCI® score 11.9 versus 18.3.

CONCLUSION

Regular comparison of individual-surgeon or -unit outcome data against benchmark thresholds may identify gaps in care quality that can improve patient outcome.

Detecting anal human papillomavirus infection in men who have sex with men living with HIV: implications of assay variability

BACKGROUND

Incidence of anal cancer (AC) caused by persistent human papillomavirus (HPV) infection has risen in the last years in men who have sex with men (MSM) living with HIV. There is consensus that this population should be screened for anal precancerous lesions, but the role of HPV DNA testing in AC screening programmes is still under debate.

OBJECTIVES

This study employed two molecular test to detect anal HPV DNA and compared assay performance and prognostic value for the diagnosis of histology proven high-grade intraepithelial anal lesions.

METHODS

MSM living with HIV attended their regular check-up visits consisting of detection of anal HPV infection, anal cytology, digital anorectal examination and high resolution anoscopy. HPV DNA was detected using Hybrid Capture 2 High-Risk test (HC2, total assay) and LINEAR ARRAY HPV Genotyping Test (LA, type-specific assay) RESULTS: Among 274 participant, prevalence of HPV DNA was 48.5% by HC2 and 89.4% by LA. HPV16 (30.6%) and HPV6 (19.6%) were the most common genotypes identified. Prevalence of multiple HPV infections was 56.2%. Agreement between HPV DNA assays was 75.2% (κ=0.51; 95% CI 0.42 to 0.60). Total HPV detection demonstrated high sensitivity (90%; 95% CI 68.3 to 98.8) and moderate specificity (58.4%; 95% CI 50.2 to 66.3), while type-specific HPV16/18 genotyping provided an increase in specificity and showed the highest area under the curve (0.81; 95% CI 0.74 to 0.89) and Youden's index (0.63).

CONCLUSIONS

Both methodologies identified a high prevalence of anal HPV infection and multiple HPV infections in MSM living with HIV, showing a moderate overall agreement between them. Either total HPV detection or type-specific HPV16/18 detection together with a threshold ≥atypical squamous cells of undetermined significance for abnormal cytology showed an acceptable diagnostic accuracy.

Comparison of two sample collection devices for anal cytology in HIV-positive men who have sex with men: Cytology brush and Dacron swab

OBJECTIVE

HIV-positive men who have sex with men (MSM) are a vulnerable group for anal cancer (AC), a cancer with a well-described precursor lesion, which can be detected early in screening programs using anal liquid-based cytology (aLBC). We aim to compare two aLBC sample collection devices: cytology brush (CB) and Dacron swab (DS).

METHODS

Retrospective analysis of two consecutive study periods, the first using CB and the second DS. Participants underwent an aLBC, a human papillomavirus (HPV) DNA test and a high-resolution anoscopy (HRA), and a biopsy was performed for suspicious lesions. The sensitivity and specificity of aLBC, area under the receiver operating characteristic (ROC) curve (AUC), and concordance between cytology and HRA were assessed using Cohen's kappa coefficient.

RESULTS

A total of 239 participants were enrolled (CB group, 120; DS group, 119). aLBC was benign in 46% of samples, and high-grade squamous intraepithelial lesion (HSIL) was detected in 11.7%. Prevalence of biopsy-proven HSIL was 15.3%. No differences in cytological and histological results were observed between the groups. aLBC-HRA concordance was weak for benign results (CB group, k = 0.309; DS group, k = 0.350) as well as for HSIL (k = 0.321 and 0.387, respectively). Sensitivity and specificity were 100% and 51.4%, respectively, in the CB group and 88% and 54.3% in the DS group (AUC = 0.711 and 0.759, respectively, P-value = .514). Representation of the transformation zone (TZ) was adequate in 83.3% of samples in the CB group and 50.4% in the DS group (P-value <.001).

CONCLUSION

Our data suggest that both devices had similar accuracy to detect anal HSIL, although samples collected with CB are more likely to have an adequate TZ representation, the presence of which could be an indicator of sample quality.

COVID-19 in the tonsillectomised population

Objective

Interactions between SARS-CoV-2 and pharyngeal associated lymphoid tissue are thought to influence the manifestations of COVID-19. We aimed to determine whether a previous history of tonsillectomy, as a surrogate indicator of a dysfunctional pharyngeal associated lymphoid tissue, could predict the presentation and course of COVID-19.

Methods

Multicentric cross-sectional observational study involving seven hospitals in Northern and Central Italy. Data on the clinical course and signs and symptoms of the infection were collected from 779 adults who tested positive for SARS-CoV-2, and analysed in relation to previous tonsillectomy, together with demographic and anamnestic data.

Results

Patients with previous tonsillectomy showed a greater risk of fever, temperature higher than 39°C, chills and malaise. No significant differences in hospital admissions were found.

Conclusions

A previous history of tonsillectomy, as a surrogate indicator of immunological dysfunction of the pharyngeal associated lymphoid tissue, could predict a more intense systemic manifestation of COVID-19. These results could provide a simple clinical marker to discriminate suspected carriers and to delineate more precise prognostic models.

Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial

Importance

Two-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis seems to provide benefits in terms of postoperative morbidity compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy and further ileostomy reversal in patients operated on for low rectal cancer.

Objective

To compare 30-day postoperative and 1-year follow-up results of Turnbull-Cutait pull-through hand-sewn coloanal anastomosis and standard hand-sewn coloanal anastomosis after ultralow rectal resection for rectal cancer.

Design, Setting, and Participants

Multicenter randomized clinical trial. Neither patients nor surgeons were blinded for technique. Patients were recruited in 3 centers, Bellvitge University Hospital and Valle d'Hebron University Hospital in Spain and Instituto Nazionale Tumori Fondazione G. Pascale-Istituto di Ricovero e Cura a Carattere Scientifico in Italy. Patients undergoing ultralow anterior rectal resection needing hand-sewn coloanal anastomosis were randomly assigned to 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis or standard hand-sewn coloanal anastomosis associated with diverting ileostomy. Data were analyzed between June 2012 and October 2018.

Interventions

All patients underwent ultralow anterior resection. Patients assigned to the 2-stage Turnbull-Cutait pull-through group underwent exteriorization of a segment of left colon through the anal canal and, after 6 to 10 days, the exteriorized colon was resected and a delayed hand-sewn coloanal anastomosis was performed. For patients assigned to standard coloanal anastomosis, the hand-sewn coloanal anastomosis was performed with diverting ileostomy at first operation. Closure of the ileostomy was planned after 6 to 8 months.

Main Outcomes and Measures

Primary outcome was 30-day postoperative morbidity. For the standard hand-sewn coloanal anastomosis with diverting ileostomy group, overall postoperative morbidity includes 30-day postoperative complications of the ileostomy closure.

Results

Ninety-two white patients, 72 men and 20 women, with a median age of 62 years, were randomized and included in the analysis. Forty-six patients received standard hand-sewn coloanal anastomosis with diverting ileostomy and 46 received the 2-stage pull-through hand-sewn coloanal anastomosis. Seven patients (15.2%) in the standard hand-sewn coloanal anastomosis group did not undergo reversal ileostomy, and 1 patient (2.2%) in the 2-stage pull-through hand-sewn coloanal anastomosis group did not undergo delayed coloanal anastomosis. The 30-day overall composite postoperative complications rate was similar between the 2 groups (34.8% in 2-stage pull-through hand-sewn coloanal anastomosis group vs 45.7% in standard hand-sewn coloanal anastomosis group; P = .40), with a difference of -10.9 (95% CI, -29.5 to 8.9).

Conclusions and Relevance

The 2-stage pull-through hand-sewn coloanal anastomosis after ultralow anterior resection for low rectal cancer is safe and does not increase the postoperative morbidity rate compared with standard coloanal anastomosis with covering ileostomy followed by ileostomy closure.

Trial Registration

ClinicalTrials.gov Identifier: NCT01766661.

Correction to: Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes

The article "Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes", written by L. Trenti, S. Biondo, A. Galvez, A. Bravo, J. Cabrera, E. Kreisler, was originally published electronically on the publisher's internet portal (currently SpringerLink) on [27 April 2017] without open access. With the author(s)' decision to opt for Open Choice the copyright of the article changed on 7 June, 2018 to

Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: A cross-sectional study

BACKGROUND

The aim of this study was to analyze the quality of life (QoL), low anterior resection syndrome (LARS) and fecal incontinence after surgery for mid to low rectal cancer and its relationship with the type of surgical procedure performed.

METHODS

A cross-sectional cohort survey study of 358 patients operated on for mid to low rectal cancer. Patients were included in three groups: abdominoperineal resection (APR), low mechanical colorectal anastomosis (CRA) and hand-sewn coloanal anastomosis (CAA). The QLQ-C30/CR29 questionnaires, LARS and Vaizey scores were used to study QoL and defecatory dysfunction. Multivariable analysis was used to estimate the prognostic effect of the variables on QoL and LARS scores.

RESULTS

62.6% of the patients answered the survey. The global QoL score was similar among APR, CRA and CAA. Patients' body image perception was significantly worse after APR than after CRA or CAA. LARS score was better in CRA group (p = 0.002). A major LARS was observed in 83.3% of the patients who underwent CAA and in 56.6% of the patients who underwent CRA. No relationship between surgical procedures and the global QoL score was observed. Neoadjuvant radiotherapy (p = 0.048) and CAA (p = 0.005) were associated with a major LARS. The Vaizey score was higher for CAA than for CRA (p = 0.036).

CONCLUSIONS

Though CAA group presents worse LARS and higher faecal incontinence scores respect CRA patients, and APR is related with a worse body image, global QoL was similar in the three groups.

Pelvic exenteration with rectal resection for different types of malignancies at two tertiary referral centres

INTRODUCTION

Pelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyse results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction.

METHOD

From January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analysed retrospectively at two national tertiary referral centers.

RESULTS

Thirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. Five-year overall survival following R0 resection was 62.6%; R1: 42.7%; R2: 24.2% (P=.018). The resection margin status was associated with overall survival, local recurrence and distant recurrence.

CONCLUSION

Pelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins.

Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer

AIM

To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer.

METHOD

Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses.

RESULTS

The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS.

CONCLUSIONS

In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.

Failure of conservative treatment with Gastrografin® for adhesive small bowel obstruction after colorectal surgery

PURPOSE

The aim of this study was to identify risk factors related with failure of conservative management of adhesive small bowel obstruction (ASBO) in patients with previous colorectal surgery.

METHODS

Patients admitted with the diagnosis of ASBO after previous colorectal resection, were included. All patients underwent administration of Gastrografin®. Abdominal radiography was done after 24 h, to confirm the presence of contrast in colon (incomplete obstruction) or not (complete obstruction). Several factors were investigated to study their relationship with the failure of conservative management. Failure of conservative management was considered when emergency operation was needed to solve ASBO.

RESULTS

Incomplete obstruction was observed in 174 episodes (93.0%) while in 13 (7.0%) was complete. One hundred seventy-one ASBO episodes (91.4%) responded successfully to nonoperative treatment and 16 (8.6%) required emergency surgery. Five patients needed bowel resection. Results on the diagnostic test with Gastrografin® showed a sensitivity of 75%, specificity of 99%, positive predictive value 92%, and negative predictive value 98%. Age over 75 years was the only predictive factor for failure of conservative management. The median waiting time from the radiologic confirmation of complete obstruction to surgery was higher in patients requiring bowel resection when compared to those who did not need resection.

CONCLUSIONS

The use of Gastrografin® in ASBO after colorectal resection is a safe and useful tool for the indication of conservative management. Age over 75 years is a predictive factor for need of surgery. Surgery should be performed no later than the following 24 h of confirmed complete obstruction.

Outcomes of colonic diverticulitis according to the reason of immunosuppression

BACKGROUND

The aims of this study were to analyze the relationship between the different causes of immunosuppression (IMS) and diverticulitis.

METHODS

IMS patients admitted for colonic diverticulitis were included in the study. Patients were divided in 5 groups according to the reasons of IMS: group I, chronic corticosteroid therapy; group II, transplant patients; group III, malignant neoplasm disease; group IV, chronic renal failure; group V, others immunosuppressant treatment. Rate of emergency surgery, outcomes in terms of postoperative mortality, and recurrence rate after nonoperative management were analyzed according to the reason of IMS.

RESULTS

Emergency surgery was performed in 76 patients (39.3%). It was needed more frequently in group I. Overall, postoperative mortality was of 31.6% and recurrence rate after successful nonoperative management occurred in 30 patients (27.8%). No differences were observed among the groups.

CONCLUSIONS

The rate of emergency surgery in IMS patients at the first episode of acute colonic diverticulitis is high. Elective surgery in IMS patients should be individually indicated according to persistence of symptoms or early recurrences.

Safety and effectiveness of renoportal bypass in patients with complete portal vein thrombosis: an analysis of 10 patients

The presence of portal vein thrombosis (PVT) is still considered by many transplantation centers to be an absolute contraindication to liver transplantation because of the technical difficulties that it can present and its association with a higher rate of patient morbidity and mortality. Renoportal bypass (RPB) can help to remove these barriers. This study describes our institution's experience with RPB through the description of a new and successful simplified surgical strategy, a patient and graft outcome analysis, intraoperative vascular flow measurements, and the use of splenic artery embolization (SAE) as an effective adjunct for treating sporadic cases of unrelieved portal hypertension. Between January 2004 and January 2013, 10 patients with grade 4 PVT underwent RPB. At the last follow-up (42.2 ± 21.1 months), the patient and graft survival rates were 100%. Five patients (50%) experienced posttransplant ascites, and 2 of those underwent proximal SAE to modulate the liver inflow and overcome the ascites. Three patients (30%) experienced transient kidney injury in the early posttransplant period and were treated efficiently with medical therapy. The renoportal flows were close to the desirable 100 mL/100 g of liver tissue in all cases. The experience and data support RPB as a feasible and easily reproducible technique without the risks and technical challenges associated with the tedious dissection of a cavernous hilum.

Incidence and management of anastomotic bleeding after ileocolic anastomosis

AIM

Ileocolic anastomosis is performed using a stapled or manual technique, but with either there is a risk of bleeding from the suture line. The aim of this study was to analyse, retrospectively, bleeding after different anastomotic techniques.

METHOD

Patients having elective right colectomy were divided, according to the type of ileocolic anastomosis, into Group 1 (circular, double-stapled, end-to-side), Group 2 (linear-stapled, side-to-side) and Group 3 (handsewn, side-to-side). Postoperative lower gastrointestinal bleeding (LGIB) was studied in the three groups. Uni- and multivariate analysis was performed to study risk factors for LGIB and the need for postoperative allogeneic blood transfusion.

RESULTS

Three-hundred and fifty patients were included: 174 in Group 1, 59 in Group 2 and 117 in Group 3. The postoperative LGIB rate was 4.9% and occurred exclusively in Group 1. Five patients had severe anastomotic bleeding. Postoperative blood transfusion was indicated in Groups 1, 2 and 3 in 19.0%, 5.1% and 13.7% of patients. In the five patients with severe bleeding, four attempts of colonoscopic arrest were made, achieving bleeding control in one. Angiographic embolization was successful in one patient. There were no procedure-specific complications.

CONCLUSION

End-to-side, circular, double-stapling ileocolic anastomosis seems to be related to an increased incidence of anastomotic bleeding and of postoperative blood transfusion compared with patients having other techniques of ileocolic anastomosis.

Emergency surgery for perforated diverticulitis in the immunosuppressed patient

AIM

Immunosuppression is believed to worsen outcomes for patients who require surgery for perforated diverticulitis. The aim of this study was to compare surgical outcomes between immunocompromised and immunocompetent patients undergoing surgery for complicated diverticulitis.

METHOD

All patients who underwent emergency surgery for complicated diverticulitis between 2004 and 2012 in a single unit were studied. Patients were classified as immunosuppressed (group I) or immunocompetent (group II). Operation type and postoperative morbidity and mortality were compared between groups. The impact of operating surgeons' specialization and the Peritonitis Severity Score (PSS) were also evaluated to determine their impact on the restoration of gastrointestinal (GI) continuity.

RESULTS

One-hundred and sixteen patients (mean age: 63.7 years), 41.4% women, were included. Fifty-three (45.7%) patients were immunosuppressed (group I): 42 underwent Hartmann's procedure (HP) (79.2%), nine (17.0%) underwent resection and primary anastomosis (RPA) with ileostomy (IL) and two (3.8%) underwent RPA without IL. In group II, 15 HP (23.8%), nine RPA with IL (14.3%) and 39 RPA without IL (61.9%) were performed. Postoperative morbidity and mortality were 79.2% and 26.4%, respectively, in group I and 63.5% and 6.3%, respectively, in group II. The overall mean PSS was 9.5, with a mean PSS of 11.1 in group I and of 8.1 in group II. The decision to perform a primary anastomosis differed significantly between colorectal surgeons and general surgeons in the patients with a PSS of 9-10-11.

CONCLUSION

In immunocompromised patients, RPA with IL can be a safe surgical option, whereas HP should be reserved for patients with a PSS of > 11. Colorectal surgical specialization is associated with higher rates of restoration of GI continuity in patients with perforated diverticulitis, especially in patients with an intermediate PSS score. Evaluation of each patient's PSS facilitates decision making in surgery for perforated diverticulitis.

Intrahepatic blood flow redistribution after temporary occlusion of the middle hepatic vein during right lobe liver donation: report of a case

INTRODUCTION

One of the critical factors that influence graft function after live donor liver transplantation is the presence or absence of global or sectorial liver congestion. Many authors advocate for routine middle hepatic vein (MHV) reconstruction because it is often difficult to determine when the MHV or one of its major branches have functional significance. Predictive tests to assess hemodynamic and functional significance of the MHV and its tributaries are still under study.

CASE REPORT

We have described a novel intraoperative manipulation and Doppler ultrasonographic evaluation that led to the decision to include the MHV with the right lobe graft.

Impact of age on recurrence and severity of left colonic diverticulitis

AIM

There has been controversy about the presentation and treatment of acute colonic diverticulitis (AD) in young patients. The aim of this observational study was to evaluate the virulence and natural history of AD in three different age groups of patients.

METHOD

The study was performed on 686 patients with the diagnosis of a first episode of AD admitted between January 1998 and December 2008. Patients were classified into three groups: age 45 years or younger (group 1), 45-70 years of age (group 2) and 70 years or more (group 3). The variables studied were gender, American Society of Anesthesiologists status, associated comorbidity, type of treatment, length of hospital stay and recurrence of AD.

RESULTS

Group 1 included 99 (14.4%) patients, group 2 339 (49.4%) and group 3 248 (36.2%). Of these, 144 patients needed emergency operation at the first admission, 25 underwent elective surgery after the first episode of AD and 10 died after medical treatment; 507 patients were followed for recurrence. In all, 104 (20.5%) patients had a recurrence of AD that required hospitalization. Fifty (9.9%) presented with one episode of severe recurrence, without any difference between the groups (P = 0.533). There were no differences in the analysis of cumulative recurrence (Kaplan-Maier) between the three groups.

CONCLUSION

AD does not present a more aggressive clinical course in younger patients and it can be safely managed using the same strategy as in middle aged and older patients.

Glucose balance of porcine liver allograft is an important predictor of outcome

BACKGROUND

The role of glucose metabolism in predicting postoperative liver graft function after transplantation is unclear. We investigated the relation between intraoperative glucose balance of the liver allograft and the postoperative graft function and survival in a porcine partial liver transplant model.

MATERIALS AND METHODS

Experiments follow Guiding Principles in the Care and Use of Animals. Fourteen female pigs received liver allografts of 17%-39% recipient liver volume. Recipients were classified into two groups based on positive glucose balance: the mean intraoperative blood glucose of the graft outflow was greater than the blood glucose of inflow, negative glucose balance: the mean blood glucose of graft outflow was less than blood glucose of inflow. Perioperative data and survival were studied.

RESULTS

In the positive group (n=9) intraoperative hepatic artery flow was significantly higher (P=0.028), and oxygen consumption was lower (P=0.018) than the negative group (n=5). Postoperatively, maximal serum aspartate aminotransferase (AST) (P=0.028), alanine aminotransferase (ALT) (P=0.028), and total bilirubin (P=0.027) of the positive group were significantly lower than the negative group. In survival analysis, the positive group had significantly better survival rate than the negative group (P=0.034). Using Periodic acid-Schiff staining, glycogen content of the allograft in the positive group at 10 min post-reperfusion was significantly decreased in comparison with the baseline value in the normal liver (P=0.005), however not statistically different in the negative group (P=0.175).

CONCLUSION

Intraoperative glucose balance can be used as an early predictor of the graft function following transplantation of partial liver allografts.

Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients?

BACKGROUND

Blood flow to the liver is partly maintained by the hepatic arterial buffer response (HABR), which is an intrinsic autoregulatory mechanism. Temporary clamping of the portal vein (PV) results in augmentation in hepatic artery flow (augHAF). Portal hyperperfusion impairs HAF due to the HABR in liver transplantation (LT). The aim of this study is to examine the effect of the HABR on biliary anastomotic stricture (BAS).

METHODS

In 234 cadaveric whole LTs, PV flow (PVF), basal HAF, and augHAF were measured intra-operatively after allograft implantation. All recipients with a vascular complication were excluded. Buffer capacity (BC) was calculated as (augHAF - basal HAF)/PVF to quantify the HABR. Recipients were divided into 2 groups based on their BC: low BC (<0.074; n = 117) or high BC (> or =0.074; n = 117).

RESULTS

Of the 234 recipients, 23 (9.8%) had early BAS (< or =60 days after LT) and 18 (7.7%) had late BAS (>60 days after LT). The incidence of late BAS and bile leakage was similar between the groups; however, the incidence of early BAS in the low BC group was greater than that in the high BC group (15% vs 5.1%; P = .0168). In the multivariate analysis, low BC (P = .0325) and bile leakage (P = .0002) were found to be independent risk factors affecting early BAS.

CONCLUSION

Recipients with low BC who may have impaired HABR are at greater risk of early BAS after LT. Intraoperative measurements of blood flow help predict the risk of BAS.

Adenosine restores the hepatic artery buffer response and improves survival in a porcine model of small-for-size syndrome

The aim of the study is to define the role of the HABR in the pathophysiology of the SFS liver graft and to demonstrate that restoration of hepatic artery flow (HAF) has a significant impact on outcome and improves survival. Nine pigs received partial liver allografts of 60% liver volume, Group 1; 8 animals received 20% LV grafts, Group 2; 9 animals received 20% LV grafts with adenosine infusion, Group 3. HAF and portal vein flow (PVF) were recorded at 10 min, 60 min and 90 min post reperfusion, on POD 3 and POD 7 in Group 1, and daily in Group 2 and 3 up to POD 14. Baseline HAF and PVF (ml/100 g/min) were 29 +/- 12 (mean +/- SD) and 74 +/- 8 respectively, with 28% of total liver blood flow (TLBF) from the HA and 72% from the PV. PVF peaked at 10 mins in all groups, increasing by a factor of 3.8 in the 20% group compared to an increase of 1.9 in the 60% group. By POD 7-14 PVF rates approached baseline values in all groups. The HABR was intact immediately following reperfusion in all groups with a reciprocal decrease in HAF corresponding to the peak PVF at 10 min. However in the 20% group HAF decreased to 12 +/- 8 ml/100 g/min at 90 min and remained low out to POD 7-14 despite restoration of normal PVF rates. Histopathology confirmed evidence of HA vasospasm and its consequences, cholestasis, centrilobular necrosis and biliary ischemia in Group 2. HA infusion of adenosine significantly improved HAF (p < .0001), reversed pathological changes and significantly improved survival (p = .05). An impaired HABR is important in the pathophysiology of the SFSS. Reversal of the vasospasm significantly improves outcome.