Surgery Open Digestive Advance最新文献

Background

Pilonidal disease is a chronic suppurative condition of the natal cleft associated with significant morbidity primarily affecting the working population causing daily discomfort and activity limitation. Although several treatment modalities have been suggested for the management of this condition, the gold standard continues to be undefined. We conducted a randomized prospective study on the treatment of Pilonidal disease by Sinus Laser Closure (SiLaC) compared with Limberg Flap.

Materials and methods

100 patients with primary Pilonidal disease were randomized to undergo either SiLaC or Limberg Flap. The primary objective of our study was to establish the advantage of SiLaC over Limberg Flap in terms of the operative time, postoperative pain, duration of hospital stay, healing time, cosmesis and recurrence rates over a period of 2 years. The patient satisfaction and return to normal activities were also documented.

Results

We analysed a total of 50 cases that underwent SiLaC and 50 that underwent Limberg Flap with similar demographic characteristics. Significantly lower operative time was noted in the SiLaC group. SiLaC was associated with decreased postoperative pain and duration of hospital stay with faster healing and better cosmetic outcome. The patient satisfaction and return to normal activites were also reported to be better in the SiLaC group. Recurrence was reported in 4 patients in SiLaC group versus 6 patients in Limberg Flap group.

Conclusion

Our study reports SiLaC as superior to Limberg Flap with shorter operative time, lower pain scores, length of hospital stay, faster healing time, decreased recurrence rates and good cosmetic satisfaction.

Purpose

Based on preclinical findings that sacral neuromodulation (SNM) reduces intestinal epithelial barrier (IEB) permeability, we conducted a clinical study in a cohort of patients with fecal incontinence to assess the impact of SNM upon ex vivo IEB permeability (rectal biopsies) and whether its variations could be predictive of therapeutic response.

Methods

In patients treated by SNM for fecal incontinence, rectal biopsies were harvested before, at the end of the test-period and after 6 months of stimulation for patients implanted. IEB permeability was assessed by measuring sulfonic acid flux across the rectal mucosa in ussing chambers (ex-vivo assessment).

Results

Ten patients (median age 67 years) suffering from fecal incontinence underwent SNM test. Following the test-period of 3 weeks long, 6 (60 %) patients were considered responders and were implanted. We noticed an increase of paracellular permeability among non-responders between baseline and the end of the test-period. Paracellular permeability was also found to be higher in the group of responders as compared to non-responders at baseline but the difference did not reach statistical significance due to small sample size. There were no complications related to rectal biopsies.

Conclusion

These data that need to be confirmed in a larger set of patients suggest that functional study of the rectal mucosa in FI patients can putatively predict the therapeutic response to SNM and can be used as a biomarker of response.

Introduction

After 20 years of high worldwide uptake of laparoscopic adjustable gastric bands (LAGB), it is estimated there are still millions of patients worldwide with an LAGB in situ. Clinicians need to be aware of some of the potential long term and unpredictable complications of LAGB. Given the site of LAGB and the propensity for malposition and adhesion formation, patients with acute and life threating LAGB complications may present with vague signs and symptoms such as lower chest pain, tachypnoea and tachycardia without peritonism on examination.

Case report

We present a 59-year-old woman with an 11-year-old LAGB in situ who presented with the aforementioned signs and symptoms erroneously diagnosed as gastroenteritis due to the lack of peritonism. After deterioration under the medical physicians, she underwent a computed tomography scan which revealed a grossly dilated gastric pouch proximal to the LAGB with volvulus. Urgent laparoscopy and gastroscopy by an upper gastrointestinal surgeon which confirmed a strangulated lateral gastric fundal pouch with focal necrosis secondary to volvulus from adhesions associated with LAGB. Due to the expedited surgery, the focal necrosis was amenable to laparoscopic omental patch repair after detorsion was performed, saving the patient further morbidity from gastrectomy, reconstruction or conversion to laparotomy. She recovered rapidly postoperatively without any long-term complications.

Conclusion

This case highlights the low index of suspicion needed to ensure such patients with LAGB in situ undergo urgent cross-sectional imaging and/or endoscopy to assess for LAGB features and associated complications and the importance of early surgical consultation.

Fecobionics is a novel integrated technology for assessment of anorectal function. It is a defecatory test with simultaneous measurements of pressures, orientation, and device angle (a proxy of the anorectal angle). Furthermore, the latest Fecobionics prototypes measure diameters (shape) using impedance planimetry during evacuation of the device. The simultaneous measurement of multiple variables in the integrated test allows new metrics to be developed including more advanced novel defecation indices, enabling mechanistic insight in the defecation process at an unprecedented level in patients with anorectal disorders including patients suffering from obstructed defecation, fecal incontinence, and low anterior resection syndrome. The device has the consistency and shape of a normal stool (type 3–4 on the Bristol Stool Form Scale). Fecobionics has been validated on the bench and in animal studies and used in clinical trials to study defecation phenotypes in normal human subjects and patients with obstructed defecation, fecal incontinence, and low anterior resection syndrome after rectal cancer surgery. Subtypes have been defined, especially of patients with obstructed defecation. Furthermore, Fecobionics has been used to monitor biofeedback therapy in patients with fecal incontinence to predict the outcome of the therapy (responder versus non-responder). Most Fecobionics studies showed a closer correlation to symptoms as compared to current technologies for anorectal assessment. The present article outlines previous and ongoing work, and perspectives for future studies in proctology, including in physiological assessment of function, diagnostics, monitoring of therapy, and as a tool for biofeedback therapy.

Introduction

The aim of the present study is to analyze the impact of preoperative antiplatelet and/or anticoagulant therapy on postoperative bleeding in proctologic surgery.

Material and Methods

A retrospective study was conducted on a consecutive series of patients who underwent to proctologic surgery between January 2016-December 2018. The patients were divided in two groups: non-therapy group without any cardiovascular problem and therapy group that received antiplatelet and/or anticoagulant therapy. A sub analysis was carried out stratifying the patients according to the type of preoperative therapy and the type of surgery.

Results

A total of 1832 operated patients were collected; 8.7 % of them received antiplatelet or anticoagulant therapy preoperatively. The postoperative bleeding rate was 2.8 % (2.1 % in the non-therapy group, and 10.1 % in the therapy group). The re-operation rate after bleeding was 1.2 % (1.1 % of non-therapy group, and 3.1 % therapy group). The re-operation rate in patients with postoperative bleeding was 51.4 % and 31.3 % for therapy and non-therapy group, respectively. The interval time between surgery and bleeding, was 7.8 days (non-therapy) and 8.5 days (therapy). Hemorrhoid's surgery showed to have the higher postoperative bleeding rate. The use of DOACs and OAC showed the highest rates of bleeding (20 % vs 36.4 %).

Conclusion

The constant increase of patients with antiplatelet/anticoagulant treatment requiring surgery for benign diseases reveals a significant increase the post-operative risk of bleeding. The management of these complex patients needs to be discussed in a multidisciplinary team with the aim to follow shared guidelines but also to customize the approach.

Although rare, Complicated Meckel's diverticulum (MD) is responsible for a variety of uncommon abdominal surgical emergency presentations. Because of these unique presentations, Meckel's diverticulum is a distinctive, peculiar astoundment in surgical practice. In this article, We reviewed previously published cases with both Gastrointestinal Stromal Tumors (GISTs) and MD to define the nature of both pathologies and their relation, the character, presentation, and timing of diagnosis of this rare coincidence. We illustrated this relation with a case of a perforated Meckel's diverticulum associated with multiple intestinal Gastrointestinal Stromal Tumors (GISTs) in a 58-year-old male presenting with features of acute appendicitis operated through a McBurney's incision.

Background

Skin adhesives are an alternative method for closure of trocar-site incisions (TSI). This systematic review and meta-analysis aim to compare the outcomes of absorbable subcuticular sutures versus skin adhesives for the closure of TSI's.

Methods

This PRISMA-compliant review was registered with PROSPERO (CRD42022325734). In April 2022, PubMed, Embase, and Web of Science were searched for peer-reviewed studies comparing the outcomes between skin adhesive and subcuticular absorbable sutures for skin closure of TSI's in adults. Primary outcomes included wound complication rate, wound cosmesis (HWES score), patient satisfaction and wound closure time. Odds ratio (OR) and mean differences (MD) were calculated with 95 % confidence intervals (95 % CI). Risk of bias was assessed with the Cochrane risk-of-bias tool.

Results

We included 10 studies and 7 were used for the meta-analysis. The wound complication rate was similar between groups (4 studies; OR: 1.39, 95 % CI: 0.74 to 2.61, p: 0.31). Wound cosmesis (4 studies; OR: 2.29, 95 % CI: 0.90 to 5.84, p: 0.08) and patient satisfaction (3 studies; OR: 1.59, 95 % CI: 0.58 to 4.38, p: 0.37) were also similar. However, wound closure time was shorter in the skin adhesives group (3 studies; MD: −22.78, 95 % CI: −40.68 to −4.89, p: 0.01).

Conclusion

We conclude that wound complications, cosmetic outcome, and patient satisfaction were comparable between TSIs closed with tissue adhesives or sutures. While wound closure with tissue adhesives was significantly faster in the meta-analysis, it is unlikely to be clinically meaningful. Future high-quality studies with higher-risk patient cohorts are required.

Pancreatic pseudocysts are fluid collections without proper wall containing pancreatic juice or liquefied necrosis, sitting within or outside the pancreas. Pancreatic pseudocysts are a common complication of chronic pancreatitis. Complications of pseudocysts include compression of neighboring organs, infection, bleeding and rupture. The surgical management of pancreatic pseudocysts can be established by various techniques. New possibilities for internal drainage are now possible with the growing popularity of minimaly invasive surgery and improvements in surgical techniques. We present a robotic-assisted surgical technique that promotes the emergency drainage of a pancreatic pseudocyst in a patient with a significant past medical history and a large hiatal hernia. The patient with a medical history of chronic calcifying pancreatitis, presented with a recent incident of an infected pancreatic pseudocyst measuring 6 × 7 cm transversely, located in the tail of the pancreas. Considering that endoscopic drainage was not possible because of a hiatal hernia with the entirely stomach located in the chest, we decided to perform a minimally invasive robotic-assisted roux-en-Y cystojejunostomy. This procedure was performed using Da Vinci Xi® robotic surgical system and lasted 180 min. Although endoscopic cystogastrostomy is an established approach, robotic-assisted cystojejunostomy is an effective and safe alternative for medical history our patient. Although endoscopic treatment is a proven method for drainage of infected pseudocysts, anatomical particularities make it not suitable. The cystojejunostomy derivation technique reported in this presentation appears to be safe and effective alternative to endoscopic therapy in contraindicated patients.

Background

It is well known that a large excisional haemorrhoidectomy could be certain cause of post-operative severe complications like incontinence, ectropion or anal stenosis.

Objective

Our aim is to reduce post-operative complications avoiding a large haemorrhoidectomy in patients suffering of a circumferential 3-4th degree prolapsed haemorrhoids.

Design

This was a prospective, single institution study with propensity score matching performing a classic stapled mucopexy followed by the excision of the internal mucosae prolapse combining at the same operative time a concomitant classic Milligan and Morgan's technique of the remnant external piles.

Patients

The study population were 54 eligible patients, study included 32, to demonstrate feasibility and safety of our proposals. 20 males, 12 females, mean age 51.9 years (range 21–84) underwent combined mucopexy and haemorrhoidectomy in one single surgical procedure between January 2017 and December 2019.

Results

A total of thirty-two patients were included prospectively and consecutively; 18 patients (33.4% of the universe) presented anatomical variations on the CMHP and variations on the IHED (10), associated anal fissures (2), modified piles with HPV condylomata (2), non-stoppable anticoagulation treatment (2), immunity treated disease (1), no evidence of a haemorrhoidal mucosal prolapse and minor pile's components (1) and they were definitely excluded of the study. There were no significant differences in the postoperative complication rates. The length of the operation was (48, 05 min +/- 5, 30 min). Some special bleeding had required at the end of the procedure a supplementary haemostasis with absorbable single suture in six patients (18, 8%), men (12, 5%) women (6, 3%). The stapled haemorrhoidal mucopexy allowed a faster functional recovery with shorter time off work (weighted mean difference 9.45 days; p < 0.00001), earlier return to normal activities (weighted mean difference, 15.85 days; P = 0.03), and better wound healing (odds ratio, 0.1; P = 0.0006). No stenosis, neither ectropion.

Limitations

Because of a single limited study including a single operative group.

Conclusions

Our results confirm the strategy, demonstrating that the combined technique drastically reduces the risk of anal stenosis, ectropion, incontinence or recurrence of the prolapse. By the restoration of the anal canal anatomy under visual control and preservation of the required mucosal and cutaneous bridges results are reproducible and sure.