Techniques in Coloproctology最新文献

Introduction: Anastomotic leakage (AL) is a serious complication after rectal cancer resection, often mitigated by diverting loop ileostomy. However, outlet obstruction remains a significant concern, potentially prolonging hospitalization and requiring reintervention. While surgical risk factors have been explored, patient-specific anatomical factors are less well understood. This study aimed to identify patient-related risk factors for outlet obstruction and evaluate a preventive surgical modification in high-risk patients undergoing laparoscopic and robotic rectal cancer surgeries.

Methods: This retrospective study included 318 patients who underwent laparoscopic or robotic rectal resection with a diverting loop ileostomy. Risk factors were assessed in a control cohort (April 2015-February 2020), followed by a modified ileostomy technique in a validation cohort (March 2020-December 2024).

Results: Increased rectus abdominis muscle thickness (TAM) and larger visceral fat area (AVF) were independent risk factors for outlet obstruction (p = 0.037 and p = 0.041, respectively). Patients with both factors had the highest incidence (52.6%). The modified technique significantly reduced obstruction among high-risk patients (p = 0.003) without increasing parastomal hernia rates.

Conclusions: TAM and AVF are independent predictors of outlet obstruction. A tailored fascial modification reduced obstruction in high-risk patients, supporting the value of preoperative anatomical assessment in surgical planning.

Background and aims: Post-endoscopic submucosal dissection (ESD) electrocoagulation syndrome (PEECS) is a recognized limitation of colorectal ESD (C-ESD) associated with morbidity, additional costs, and prolonged admission. Reliable closure of C-ESD defects can decrease the incidence of PEECS. We introduce a novel mucomuscular closure technique that involves direct closure of the muscularis propria using through-the-scope clips (TTSC). We evaluate the feasibility and efficacy of the modified closure technique in prevention of post-C-ESD PEECS.

Methods: We conducted a prospective cohort study of consecutive C-ESDs at a single tertiary center between January 2017 and October 2023. Patients who underwent C-ESD with mucomuscular closure or conventional closure with TTSC were enrolled. The primary outcome was the incidence and clinical outcome of PEECS. Secondary outcomes were rates of complete defect closure and severe adverse events (SAEs).

Results: A total of 764 patients were included in this study. The incidence of PEECS was significantly lower in the mucomuscular closure group versus conventional closure group (2.5% versus 15.0%, P < 0.001). No SAEs occurred in mucomuscular closure group, whereas two patients had delayed perforation, and two had delayed bleeding in the conventional closure group. In mucomuscular closure group, there was no difference in PEECS occurrence between complete closure (5/218, 2.3%) and partial closure (3/105, 2.9%). No TTSC-related perforation occurred in the process of defect closure.

Conclusions: Mucomuscular closure with TTSC in C-ESDs is effective in preventing PEECS and other postoperative complications.

Introduction: In sacral neuromodulation (SNM), the stimulation intensity is set at the sensory threshold (ST) level. However, subsensory stimulation as low as 50% of ST has proven effective in reducing faecal incontinence episodes.

Aim: To explore the relationship between functional outcomes and varying subsensory stimulation amplitude in newly implanted patients.

Method: This randomised, double-blind study was designed to include patients with ≥ 1 faecal incontinence episodes/week despite maximal conservative therapy. As part of another trial, patients were offered a one-stage procedure. Postoperatively, patients were randomised into two groups. G-1 received stimulation at 0.05 V, at 50% and 90% of the ST in three 4-week periods, followed by 12 weeks of stimulation at the ST. G-2 received stimulation at 90% of the ST in three 4-week periods, followed by 12 weeks of stimulation at ST. Patients were evaluated after each period using St. Marks's Incontinence Score and a visual analogue scale (VAS) for patient satisfaction regarding social function, bowel function and quality-of-life, along with a bowel habit diary.

Results: In total, 73 patients with a median age of 60 years [interquartile range (IQR: 50-69 years)] completed the trial. Faecal incontinence episodes were significantly reduced at all follow-ups, with no differences between groups. The only statistical difference between groups was deltaVAS for bowel function after 4 weeks. In G-1 with ultra-low stimulation amplitude [0.05 V - equivalent to 9.6% (IQR: 6.5-13.4) of ST], the improvement compared with baseline was 30 points (IQR: 10-50) significantly lower than G-2 with an improvement of 50 points (IQR: 10-70) (p-value: 0.05).

Conclusions: Subsensory stimulation is feasible in newly implanted patients with faecal incontinence. An amplitude of 0.05 V is as effective on the functional outcomes as stimulation with higher amplitudes.

Background: Complex perianal fistulas present a significant surgical challenge due to high recurrence rates and the need to preserve sphincter function. Fistula-tract Laser Closure (FiLaC™) is a minimally invasive technique that offers promising results, but incomplete closure of the internal opening remains a major cause of recurrence. To improve outcomes, we propose the FiLaFlap technique, which combines FiLaC™ with a mucosal advancement flap to enhance fistula healing.

Methods: We conducted a retrospective study of patients who underwent seton removal with the FiLaFlap procedure between January 2023 and September 2024. Postoperative data, including pain levels, complications, continence status, and follow-up outcomes, were collected prospectively. Patients underwent clinical evaluations and 3D endoanal ultrasound assessments at predefined intervals.

Results: A total of 24 patients (58.3% male, mean age 39.4 ± 12.4 years) were included. The mean time between seton placement and FiLaFlap was 5.95 ± 1.78 months. Postoperative pain was low (VAS 2.20 ± 0.97), and no major complications occurred. At 6 months, 91.6% of patients achieved clinical remission, while 83.3% had ultrasound-confirmed healing. Only one patient reported minor incontinence.

Conclusion: The FiLaFlap technique appears to be a safe and potentially effective sphincter-preserving strategy for complex perianal fistulas, demonstrating high remission rates with minimal morbidity. Further studies with larger cohorts and extended follow-up are needed to validate these preliminary findings.

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical option for patients with ulcerative colitis (UC) wishing to avoid a permanent ileostomy. Single-port (SP) robotic surgery offers enhanced dexterity and visualization, potentially overcoming the limitations of single-port laparoscopy in the confined pelvic cavity. Its role in IPAA for UC is unexplored.

Methods: Patients with ulcerative colitis undergoing SP robotic proctectomy with IPAA at a tertiary center between October 2024 and June 2025 were reviewed. Procedures followed a standardized three-step approach with transanal transection single stapled (TTSS) anastomosis. Feasibility was defined as completion of the procedure without unplanned conversion to multiport laparoscopy, laparotomy, or transanal minimally invasive surgery (TAMIS). Safety by 30-day postoperative morbidity, readmission, and pouch leak rates was analyzed.

Results: A total of 14 patients (median age 34 years; body mass index (BMI) 26.2 kg/m²) were included. Median operative time was 237 min (range 188-317 min). Hospital stay was 5.8 days (range 3-12 days). No conversions occurred; one case required the unplanned placement of additional 5-mm assistant trocar. Four patients (28.5%) developed postoperative complications. The mean Comprehensive Complication Index was 7.6 ± 12.8 (SD). Three patients (21.4%) required readmission within 30 days postoperatively. All patients underwent ileostomy closure at a median of 64 days after IPAA creation.

Conclusions: SP robotic proctectomy with IPAA is feasible and safe in unselected patients with UC, supporting further large prospective evaluation.

Background: The efficacy of adjuvant antibiotic therapy in reducing the rate of fistula following incision and drainage (I and D) of cryptoglandular anorectal abscesses remains controversial. This study evaluated the effect of adjuvant antibiotic therapy on fistula formation rate.

Methods: This retrospective study included all consecutive adult patients who underwent I and D for a cryptoglandular anorectal abscess between January 2011 and December 2024 at a university-affiliated institution. Demographic, clinical, and microbiological culture data were collected. The intervention assessed was adjuvant antibiotic therapy administration for a minimum of 7 days following I and D. The primary outcome compared fistula formation rates at 12 months after I and D between those who received adjuvant antibiotic therapy and those who did not. Secondary outcomes assessed the factors associated with fistula formation.

Results: Of the 770 patients who met inclusion criteria, 60.5% received adjuvant antibiotic therapy. The overall rate of fistula was 6.8%. The overall median time to diagnosis was 15.4 weeks (interquartile range [IQR]: 7.7-31.3). No differences in the fistula formation rate or time to diagnosis were observed between the two groups. Fistula formation was significantly associated with abscess location, whereas diabetes mellitus was less common among patients who developed fistula. In addition, no patient whose abscess culture yielded skin-derived microorganisms developed a fistula. Age > 40 years and intersphincteric abscess were associated with fistula formation in multivariate analysis, while diabetes mellitus demonstrated a negative association.

Conclusions: In this retrospective study, adjuvant antibiotic therapy was not associated with a decreased risk of fistula formation following abscess I and D.

Background: Colorectal cancer (CRC) remains a global health concern, underscoring the importance of effective bowel preparation for diagnostic procedures such as colonoscopy. This randomized controlled trial was designed to compare the efficacy and tolerability of orally administered mannitol and polyethylene glycol (PEG) solutions for repeat colonoscopy in patients with inadequate bowel preparation.

Methods: This prospective, open-label, noninferiority, blinded end point, randomized controlled clinical trial enrolled patients from two centers. Participants aged 18-75 years with Boston Bowel Preparation Scale (BBPS) scores ≤ 1 in any colon segment were included. The study employed a 1-L mannitol or PEG solution, with primary outcomes assessed using BBPS scores. The secondary outcomes included adverse events, taste preferences, and patient satisfaction. A simple randomization strategy was employed, and both intention-to-treat (ITT) and per-protocol (PP) analyses were conducted.

Results: A total of 134 patients were included in the study, and the trial demonstrated the noninferiority of mannitol compared to PEG in achieving adequate bowel preparation (difference 3.0%, 95% confidence interval - 5.0 to 11.0%). Mannitol exhibited favorable trends in BBPS scores, highlighting its effectiveness. The safety profiles of the two solutions were comparable, with a low incidence of adverse events (17.9% vs. 19.4%, P = 0.825). Notably, mannitol outperformed PEG in terms of patient satisfaction and a greater inclination for reuse.

Conclusion: The findings suggest that orally administered mannitol is not inferior to orally administered PEG in patients with inadequate bowel preparation.

Registration number: ClinicalTrials.gov, NCT05912114. Registered on 12/6/2023.

Background: Internal hernia with small bowel obstruction after laparoscopic colorectal resection is a rare but potentially life-threatening complication, especially when it occurs after left hemicolectomy. While several studies have suggested that the closure of mesenteric defects may prevent internal hernias, the optimal preventive strategy has yet to be determined.

Methods: We describe a surgical technique designed to reduce the risk of internal hernia after left-sided colorectal resection, involving complete mobilization of the proximal jejunum, followed by its alignment and fixation to the epiploic appendages over the reconstructed left mesocolon.

Results: From November 2024 to February 2025, the aforementioned surgical procedures were successfully performed in 25 patients who underwent laparoscopic colorectal resection with splenic flexure mobilization. No symptomatic or asymptomatic internal hernias were observed during the follow-up computed tomography (CT) scan (3-6 months).

Conclusions: This novel technique has the potential to reduce internal hernias. Further studies are required.

This case report describes the laparoscopic technique of infrapyloric lymph node dissection as part of a complete mesocolic excision (CME) for right-sided colon cancer. While controversial and not routinely performed, this extended dissection is indicated in the presence of specific risk factors for nodal metastasis, such as elevated CEA (> 17 ng/ml) and obstructive symptoms, as presented in our 88-year-old patient. The article outlines the key surgical steps to safely clear the infrapyloric region, emphasizing ligation of the right gastroepiploic vessels and meticulous dissection to minimize bleeding and chyle leakage.