Techniques in Coloproctology最新文献

Background: Quality of life (QoL) and functional outcomes after redo ileoanal pouch (IPAA) surgery are worse than after primary (index) pouch surgery. However, QoL in failing pouches compared to after redo IPAA has not been reported. We hypothesized that QoL after redo IPAA would be improved compared with failing IPAAs immediately prior to redo surgery.

Methods: Adults who underwent redo IPAA (1984-2024), had successful loop ileostomy closure, and at least one pouch survey were included. Our primary outcome was the Cleveland Global Quality of Life Index (CGQLI; range, 0 [lowest] to 1 [highest]). Survey responses before and after redo IPAA were compared using unmatched and matched pair analyses.

Results: A total of 528 redo pouches were included: pouch excision with neo-IPAA in 318 (60%) and pouch repair with neo-IPAA in 210 (40%); 298 (56%) had follow-up survey data available. After redo IPAA, social, work, and sexual restrictions all decreased (p ≤ 0.05), and bowel movements decreased from 10 to 8 per 24 h (p = 0.05), whereas urgency, incontinence, seepage, pad usage, fiber, antidiarrheal usage, and dietary restrictions were comparable to before redo IPAA. After redo IPAA, quality of health, quality of energy, QoL, and CGQLI were significantly higher than those before redo IPAA (p < 0.0001). When surveyed after redo IPAA, 86% of patients would undergo redo surgery again, 88% would recommend redo IPAA, and happiness with surgery increased (p = 0.001).

Conclusion: Redo IPAA improved quality of life and restrictions observed prior to redo pouch surgery without compromising functional outcomes for most patients.

Background: Complete rectal prolapse, associated incontinence and obstructive symptoms, significantly impairs quality of life. Minimally invasive ventral mesh rectopexy, the current standard, being transperitoneal, entails risks of vascular, bowel injury, and adhesions, besides mesh and tack fixation issues. This study evaluates the feasibility, safety, and short-term outcomes of a novel total extraperitoneal anterior rectopexy that avoids peritoneal transgression and sacral fixation.

Methods: In this prospective single-center study conducted from July 2024 through the time of publishing, 20 patients (11 male, 9 female; mean age 34.6 ± 14.2 years) with complete rectal prolapse who had a body mass index < 28 kg/m² and who had not had prior abdominal surgery underwent this procedure, which involved transfascial rectal fixation to the abdominal wall with preperitoneal mesh placement. Operative variables, complications, recurrence, functional outcomes [St. Mark's Incontinence Score (SMIS), obstructed defecation syndrome (ODS) score, quality-of-life questionnaires], sigmoidoscopy, manometry, and defecography were assessed.

Results: Mean operative time was 181.2 ± 41.6 min, blood loss 70.6 ± 30.6 mL, and hospital stay 4.1 ± 2.7 days. During median 8-month follow-up, two patients (10%) experienced mucosal prolapse. There was no mortality nor were there major complications. Four patients developed transient hematuria, resolving conservatively. Significant improvements were observed in SMIS (18.6 ± 2.4 to 14.4 ± 2.8; p = 0.0357) and ODS scores (16.3 ± 3.2 to 8.1 ± 3.9; p < 0.0001). Quality-of-life improved, while manometric and defecographic parameters were not significantly altered.

Conclusions: Total extraperitoneal anterior rectopexy is feasible and safe, avoiding peritoneal entry and sacral fixation while achieving favorable early outcomes. Larger, long-term validation is needed.

Background: Low anterior resection syndrome (LARS) is a common postoperative sequala affecting up to 70% of patients following rectal cancer surgery. Characterized by urgency, frequency, incontinence, and incomplete evacuation, LARS can significantly impair quality of life. Sacral neuromodulation (SNM) has emerged as a potential therapy for patients with refractory symptoms.

Methods: This retrospective single-center study included 43 patients with LARS unresponsive to conservative therapy who underwent SNM between 2017 and 2025. All patients received the InterStim™ device following a positive test phase. Demographic, clinical, and surgical data were collected and analyzed. The primary outcomes were changes in LARS and Wexner incontinence scores. Secondary outcomes included changes in quality of life measured by the Fecal Incontinence Quality of Life (FIQL) questionnaire and Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) survey.

Results: LARS scores improved from a mean of 37.9-29.9 (p < 0.001) and Wexner scores from 14.2 to 10.4 (p < 0.001). FIQL scores improved significantly across all subdomains: lifestyle (1.49-2.28, p < 0.001), coping (1.39-2.26, p < 0.001), depression (1.66-2.38 p < 0.001), and embarrassment (1.58-2.40, p < 0.001). PROMIS-10 scores also improved, with physical health increasing from 35.7 to 41.4 (p = 0.01) and mental health from 40.3 to 45.1 (p = 0.02). Six patients required device revision, and three experienced minor complications.

Conclusions: SNM significantly improves bowel function and quality of life in patients with LARS refractory to conservative management and represents a promising therapeutic option.

Background: Colon cancer located at the splenic flexure exhibits dual lymphatic drainage via the left middle colic artery (lt-MCA) to the superior mesenteric artery (SMA) system and the left colic artery (LCA) to the inferior mesenteric artery (IMA) system. However, an additional pathway-the Arc of Riolan (AoR) artery, central anastomotic vessels connecting the SMA and IMA-may also serve as a route for metastasis. This case highlights the importance of central vascular ligation of the AoR in splenic flexure cancer.

Case: We present a rare case of isolated AoR lymph node metastasis in a 72-year-old male with advanced splenic flexure cancer. The patient presented with multiple synchronous tumors (splenic flexure, sigmoid, and rectum) and underwent extended left hemicolectomy with central vascular ligation (CVL) of the AoR, revealing metastatic involvement exclusively in AoR nodes. This represents the first documented case of isolated AoR nodal metastasis, emphasizing the need for AoR lymphadenectomy when present.

Discussion: Recent studies suggest that accessory middle colic arteries (aMCA) and AoR may represent the same anatomical structure, with metastasis rates of 3.7-6.3% in corresponding nodes. Our findings support that AoR should be considered a critical target for CVL in splenic flexure cancer, particularly when identified pre- or intraoperatively.

Conclusions: Surgeons should recognize AoR as a possible isolated metastatic pathway and perform thorough nodal dissection along this vessel when present to ensure optimal oncologic outcomes.