Techniques in Coloproctology最新文献

Background: Anal injuries, such as lacerations and fissures, are challenging to diagnose because of their anatomical complexity. Endoanal ultrasound (EAUS) has proven to be a reliable tool for detailed visualization of anal structures but relies on expert interpretation. Artificial intelligence (AI) may offer a solution for more accurate and consistent diagnoses. This study aims to develop and test a convolutional neural network (CNN)-based algorithm for automatic classification of fissures and anal lacerations (internal and external) on EUAS.

Methods: A single-center retrospective study analyzed 238 EUAS radial probe exams (April 2022-January 2024), categorizing 4528 frames into fissures (516), external lacerations (2174), and internal lacerations (1838), following validation by three experts. Data was split 80% for training and 20% for testing. Performance metrics included sensitivity, specificity, and accuracy.

Results: For external lacerations, the CNN achieved 82.5% sensitivity, 93.5% specificity, and 88.2% accuracy. For internal lacerations, achieved 91.7% sensitivity, 85.9% specificity, and 88.2% accuracy. For anal fissures, achieved 100% sensitivity, specificity, and accuracy.

Conclusion: This first EUAS AI-assisted model for differentiating benign anal injuries demonstrates excellent diagnostic performance. It highlights AI's potential to improve accuracy, reduce reliance on expertise, and support broader clinical adoption. While currently limited by small dataset and single-center scope, this work represents a significant step towards integrating AI in proctology.

Background: The diverse range of therapeutic options for hemorrhoidal disease (HD) highlights the need for precise classification systems to guide treatment. Although the Goligher classification remains the most widely used, it has been criticized for its simplicity and limited ability to capture symptom severity or guide treatment decisions. This study aims to evaluate the patient selection criteria and classification systems employed in randomized controlled trials (RCTs) for HD.

Methods: A systematic review was conducted following the 2020 PRISMA guidelines. A comprehensive search of databases identified randomized controlled trials (RCTs) comparing treatments for HD, focusing on classification systems used for patient enrollment. Eligible studies included adult patients and at least one arm involving surgical treatment.

Results: Out of 6692 records, 162 studies met the inclusion criteria, with a median cohort size of 84 patients and 55.4% male. Most studies (86.4%) used the Goligher system, though the majority did not fully describe or cite the system. Only 13.6% of studies employed more recent alternative classification systems. The most common outcome measures across studies were postoperative pain (147 studies) and complications (133 studies). Recurrence rates were reported in 42% of studies, yet 70% of these did not provide adequate inclusion criteria or references to Goligher's classification.

Conclusions: The inconsistent application of the Goligher classification and the variability in patient selection criteria across RCTs highlight the need for more nuanced and standardized systems. Future research should focus on refining classification methods and incorporating patient-reported outcomes to improve the reliability and relevance of HD trials.

Prospero registration: CRD42023387339.

Background: Fistula tract laser closure (FiLaC) represents a minimally invasive, sphincter-sparing technique for managing fistula in ano with increasing popularity among proctologists. Despite its increasing adoption, significant variations exist in the application of FiLaC in daily practice.

Purpose: The aim of these recommendations was to define some basic principles and recommendations for performing a standard FiLaC procedure.

Methods: The recommendation development group (RDG) consisting of surgeons with experience in the FiLaC were invited to formulate recommendations for the procedure. The recommendations were generated following systematic literature research and discussion amongst experts (expert opinion) where no substantial literature was available. The developed recommendations were voted upon by a panelist via the Delphi process. Consensus was a priori defined as agreement of 75% and above.

Results: The RDG developed 25 recommendations that were voted upon by 21 panelists from 13 nations. Consensus was reached for all 25 recommendations after the first Delphi round.

Conclusion: The FiLaC RDG offers a comprehensive suite of recommendations to enhance the safety and efficacy of standard FiLaC procedures. These 25 detailed recommendations collectively address the full spectrum of FiLaC procedures-from laser settings, preoperative preparations, and perioperative strategies to postoperative care. This coherent framework is anticipated not only to standardize but also to refine the FiLaC technique to ensure best possible surgical outcomes while preserving patient safety.

Background: Functional outcomes and quality of life (QoL) of transverse coloplasty pouch (TCP) in intersphincteric resection (ISR) for ultralow rectal cancer remain poorly understood.

Methods: A prospective analysis was conducted on patients who received ISR treatment from January 2020 to May 2022. Patients were divided into TCP and straight coloanal anastomosis (SCAA) groups. Comparisons were made for low anterior resection syndrome (LARS) score, Wexner incontinence score (WIS), Kirwan's incontinence score, visual analog scale (VAS), and fecal incontinence quality of life (FIQL) questionnaire at 3, 6, and 12 months post ileostomy closure. Additionally, anorectal manometry outcomes were compared pre ileostomy closure.

Results: A total of 75 patients were included, with 25 in the TCP group and 50 in the SCAA group. At 3, 6, 12 months post ileostomy closure, the TCP group showed significantly lower LARS (31, 30, 28; p = 0.033, 0.044, 0.019, respectively), WIS (11.04, 9.92, 7.32; p = 0.025, 0.043, 0.007, respectively), and Kirwan's incontinence scores (p = 0.044, 0.033, 0.022). Additionally, the TCP group showed higher VAS (5, 6, 7; p = 0.004, 0.006, 0.005, respectively) and FIQL summary scores (2.67, 2.79, 2.86; p = 0.001, 0.002, 0.004, respectively). Prior to ileostomy closure, the rectal first sensation and maximum tolerance volumes were significantly higher in the TCP group compared to the SCAA group (22 ml vs. 20 ml, 51.56 ml vs. 34.52 ml; p = 0.019, 0.038, respectively). There were no significant differences in postoperative complications or recurrence rates between the groups.

Conclusions: TCP is a safe technique, which may improve bowel function and QoL in ISR patients with low rectal cancer within 1 year.

Background: Given that a surgeon's technical skills affect not only short- but also long-term outcomes, adequate surgical training is very important. We developed the world's first training simulator for laparoscopic right hemicolectomy that does not use animal tissue, called COLOMASTER, which was designed to accurately reproduce the anatomical and membrane structures of the human body. Here, we report the features of COLOMASTER.

Methods: Dry polyester fibers were used to reproduce the multilayered membrane structure, and the adhesive strength of the layers was controlled using bonding technology, allowing realistic peeling techniques. Hydrogel was used to achieve electrical conductivity.

Results: COLOMASTER allows surgeons to simulate the entire surgical step and practice complete mesocolic excision, central vascular ligation, and intracorporeal anastomosis, the importance of which has been reported in recent years.

Conclusion: We present the world's first right hemicolectomy simulator that does not use animal tissue and believe that it will contribute to efficient off-the-job training.

Background: The aim of this study was to assess the environmental impact, primarily the carbon footprint of the most common procedures in inflammatory bowel disease (IBD).

Methods: In this study, all processes and products used during a total of eight laparoscopic ileocecal resections (ICRs) in patients with Crohn's disease (CD), eight laparoscopic subtotal colectomies (STCs) for ulcerative colitis (UC), and eight ligation of the intersphincteric fistula tract (LIFT) procedures in patients with Crohn's perianal fistula (PAF) (all in adults ≥ 16 years) between March 2023 and May 2024 were collected. A life cycle assessment (LCA) was conducted, mean CO² emission rates were calculated, the major contributors ("hotspots") were determined, and midpoint/endpoint analysis was performed.

Results: The mean total carbon footprints of laparoscopic ICR, STC, and LIFT were, respectively, 104 kg, 116 kg, and 43.6 kg CO²eq, equaling one-way trips by airplane from Amsterdam to Paris, to Manchester, and to Düsseldorf, respectively. The main contributors in laparoscopic ICR and STC were transport of employees and patients (48% and 49%, respectively), energy use in the theater (21% and 27%, respectively), and the use of surgical equipment (14% and 17%, respectively). In LIFT procedures, transport of employees/patients accounted for 47% of total emission rates, followed by the use of surgical equipment (28%), and electricity use in the theater (13%). Besides the impact on global warming, significant impact on fine particulate matter formation, land use, terrestrial acidification, and fossil resource scarcity was identified. Endpoint analysis showed an amount of disability-adjusted life years (DALYs) of approximately 2 h of health damage per laparoscopic ICR/STC and 47 min per LIFT.

Conclusions: The carbon footprint of three commonly performed IBD surgeries is mainly determined by transportation of patients/healthcare personnel, followed by electricity and material use. The latter two vary with the complexity of the surgeries. IBD surgeons should focus on minimizing energy resources and using standard surgical materials. Also, employees should be encouraged to travel by foot/bicycle/public transport/carpooling/electric car.

Background: Patients with locally advanced rectal cancer (LARC) treated with (chemo)-radiotherapy before abdominoperineal resection (APR) are at high risk of developing pelvic organ/space surgical site infection (O/S-SSI). This increases morbidity and prolongs length of stay. Vague symptoms delay diagnosis. In microdialysis, thin catheters are placed in tissue enabling monitoring of metabolism. We hypothesize that local metabolic changes related to O/S-SSI might be detected by microdialysis.

Methods: In a prospective observational study, 38 patients who underwent open APR for LARC were analysed. At the end of surgery microdialysis catheters were placed in remnant tissue of the pelvic floor. Postoperatively, metabolic parameters including lactate, pyruvate, glucose and glycerol were measured, and the lactate-to-pyruvate (L/P) ratio was calculated. Out of 38 patients, 12 (32%) developed O/S-SSI.

Results: O/S-SSI was diagnosed median 9 (range 6-17) days after surgery. On the day of surgery, mean lactate in the O/S-SSI group was 6.0 mmol/L, whereas it was 3.6 mmol/L in the no-O/S-SSI group. ROC analysis (AUC = 0.73), with cut-point lactate 5.7, detected O/S-SSI with 92% sensitivity and 65% specificity. Overall mean lactate was 1.9 mmol/L higher in the O/S-SSI group than in the no-O/S-SSI group (P = 0.002). Overall mean L/P ratio was 34 units higher in the O/S-SSI group (P = 0.001).

Conclusions: In patients developing pelvic O/S-SSI, tissue lactate and L/P ratio measured by microdialysis were significantly higher and evident already from the day of surgery, 9 days prior to diagnosis, with high negative predictive value and moderate positive predictive value. Local monitoring using microdialysis may aid detection of O/S-SSI.

Background: Anterior rectocele is one of the most common colorectal problems with symptoms of obstructed defecation or rectal emptying difficulties. The aim of this study is to compare the outcomes of laparoscopic ventral mesh rectopexy (LVMR) and transvaginal repair (TVR) for symptomatic anterior rectocele.

Methods: This is a prospective randomized controlled trial conducted with 40 women. Patients were randomized into two groups. LVMR was done in the first group, whereas the second group underwent TVR. Patient outcomes were compared regarding improvement in constipation using the Cleveland Clinic Constipation (CCC) score and sexual-related quality of life score using the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at 6- and 12-month follow-up.

Results: Forty females were enrolled in this trial. Each group comprised 20 patients. Preoperatively, the CCC score was 17 ± 2.8 in the LVMR group vs. 17.3 ± 2 in the TVR group (P = 0.278). A significant decrease in the constipation score was recorded in each group at 6 and 12 months after surgery. Regarding sexual function, the mean PISQ-12 score at 6 months was 32 ± 3.9 for LVMR vs. 35 ± 1.4 for TVR, P < 0.001), while at 12 months no difference was noted between the two groups. However, each group showed significant improvement in the PISQ-12 score at 6- and 12-month follow-up.

Conclusion: Comparable results were noted for LVMR and TVR in management of anterior rectocele. Obstructive defecation symptoms and sexual function showed significant improvement after 1 year of follow-up. Nevertheless, long-term follow-up is needed.

Clinical trial registration: The study was registered in the clinical trials registry with registration number NCT06633172.

Background: Large polyps have a higher risk of muscle retracting sign (MRS) positivity and display higher incomplete resection rates by endoscopic submucosal dissection (ESD). Techniques used are pocket creation methods and circumferential excision with traction application. This is a pilot study aiming to explore the efficacy and safety of a new ESD technique for MRS+ lesions.

Methods: First, a 5-cm-long tunnel is created distally from the lesion, stabilizing the scope and enabling a deeper, flatter dissection plane. As the resection nears the lesion's center with suspected MRS, a local pocket is made for circular access to the muscle retraction tip. Effective gravity management is key for procedure success. Initially working against gravity (or opposite to the direction of gravity) allows better submucosal exposure. Subsequently, patient position is adjusted to allow the specimen to be pulled by gravity towards the dissection line. As a result, the altered position loosens the muscle layer, thereby reducing the tension at the MRS site and ultimately the perforation risk. Finally, a circumferential "360° dissection" is performed, with prophylactic coagulation applied at the muscle retraction tip to minimize bleeding from large feeding vessels.

Results: Our cases series consists of 18 patients who underwent ESD for MRS+ colonic (3/18) and rectal (15/18) giant (> 4 cm) lesions, with en bloc and R0 resection documented in 16/18(89%) cases. Two patients were referred to surgery because of massive MRS+ and high risk of severe intraprocedural bleeding.

Conclusions: This case series demonstrates the efficacy of the aforementioned technique, yielding satisfactory results in the majority of cases-even those without curative resection. The application of this technique not only in giant rectal polyps but also in colonic protruding lesions amplifies the significance of the proposal.