Techniques in Coloproctology最新文献

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.

Introduction: Perianal fistulas often require multiple surgical interventions because of their chronic nature. Various sphincter-sparing techniques achieve clinical closure rates of up to 70%, yet recurrence remains a major challenge. Vacuum-assisted closure (VAC) therapy has shown promise in wound healing, but its application in perianal fistulas remains largely unexplored. The Semiflex catheter was developed to facilitate outpatient vacuum therapy without the need for general anesthesia during catheter exchanges. This pilot study aimed to evaluate the feasibility and clinical applicability of the Semiflex catheter in perianal fistula management.

Methods: The Semiflex pilot study was a two-part feasibility trial. The first part assessed proof of principle in ten patients, while the second part, a multicentre study, aimed to confirm feasibility in 20 patients. Feasibility included smoothness of insertion and changing of the Semiflex catheters, capability of proper fixation of the Semiflex catheter, maintaining vacuum for more than 48 h, and compliance to the therapy in terms of pain and discomfort. The protocol was scored feasible if at least 50% of the exchanges met all these criteria in at least 70% of patients. Secondary outcomes included clinical fistula closure, radiological healing, and treatment-related adverse events.

Results: Twenty patients were included (median age 39.5 years; 70% Crohn's disease). Thirteen Semiflex treatments were scored as feasible, below the predefined threshold. Clinical fistula closure was observed in 50% of patients, but none showed radiological healing at 3 months. One serious adverse event occurred, requiring early treatment discontinuation, while minor complications, including local skin reactions and pressure sores, were managed conservatively.

Conclusions: Semiflex therapy was feasible in a subset of patients and allowed outpatient treatment. However, maintaining vacuum and achieving long-term fistula closure remains challenging. While Semiflex may have a role in perianal fistula management, further research is needed to refine patient selection and optimize its application.

Introduction: Limited data exists in literature regarding concomitant ventral rectopexy (VRP) and sacrocolpo/hysteropexy (SCP/SHP), with existing studies being predominantly retrospective. The aim of this meta-analysis is to assess the anatomical and functional outcomes of combined VRP and SCP/SHP for the treatment of multicompartmental pelvic organ prolapse (POP).

Methods: We performed systematic research and meta-analysis from PubMed/MEDLINE and EMBASE, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, until 15 January 2025. Women submitted to VRP with SCP/SHP were included. Improvement of anorectal symptoms were evaluated. Postoperative anatomical relapse was reported. Re-operation rates were evaluated.

Results: Six articles were included. Constipation/obstructed defecation syndrome (ODS) [odds ratio (OR) 0.26, 95% CI 0.10-0.68; p = 0.006 (I² test 81%, p = 0.56)] and of anal/fecal incontinence (AI/FI) rates [OR 0.09, 95% CI 0.03-0.30; p < 0.0001 (I² test 70%, p = 0.04)] significantly improved after combined VRP and SCP/SHP. The proportion metanalysis of four included studies reported a subjective POP recurrence rate of 7% (95% CI 1-13%; I² test 82.9%, p < 0.001). The proportion metanalysis of five included studies for objective POP recurrence was 5% (95% CI 1-9%; I² test 56.9%, p = 0.041). No serious adverse events were reported.

Conclusions: VRP combined with SCP/SHP has been shown to be safe and effective for women with multicompartment POP, providing optimal anatomical and functional outcomes. Larger, long-term, prospective-controlled studies are needed to confirm these results.

Introduction: Unhealed wounds and persistent perineal sinuses (PPS) may occur in as many as one third of patients after proctectomy for Crohn's disease. The management of these conditions remains a significant challenge, particularly in the context of inflammatory bowel disease (IBD), with existing therapies plagued by high failure rates. This systematic review of the literature assessed the efficacy of medical and surgical therapy for PPS closure in IBD. Secondary aims included review of classification systems used for PPS.

Methods: A literature search was conducted using Medline, Embase and Cochrane databases on 17 December 2024. The review was registered on PROSPERO (CRD42024622582). Inclusion criteria were adult patients with IBD and PPS or unhealed wounds following proctectomy. We excluded abstract-only publications, case reports, cancer and paediatric cohorts. Two reviewers independently screened abstracts and full texts and extracted data. The primary outcome was clinical healing rate. Secondary outcomes included classification systems used to describe PPS. Risk of bias was assessed.

Results: Of 496 records identified, following removal of duplicates, 489 abstracts were screened, and 60 full text articles assessed for eligibility. Of 25 articles included in the final analysis, 23 were case series or retrospective cohort studies, and all were at high risk of bias. No randomised controlled trials were identified. Five articles (including two of the case series) described classification systems for PPS. Interventions included hyperbaric oxygen therapy, Karydakis flap, cleft closure, omentoplasty, skin grafting, gracilis and rectus abdominis flap, platelet-derived growth factor, curettage, lay open and excision of sinuses. Reported healing rates ranged from 30% to 100%. Heterogeneity in the reporting of outcomes, as well as the interventions performed precluded meta-analysis.

Conclusion: The published evidence for treatment of PPS in IBD consists of low-quality evidence case series with high risk of bias. There is a need for standardised outcome reporting and high-quality, prospective studies to establish effective treatment algorithms.

Background: Transsphincteric anal fistula is a common and challenging diagnosis for patients and surgeons alike. Ligation of the intersphincteric fistula tract (LIFT) following non-cutting seton placement represents an established definitive treatment with many technical variations. Unfortunately, up to 53% of attempted LIFTs fail. We aim to describe a modified LIFT approach and evaluate outcomes at our institution.

Methods: Thirty-two patients from 2021 to 2024 underwent the modified LIFT approach which included the offsetting of the transected fistula ends with interposing muscle plication, along with closure of the internal opening, and wide excision of the external opening. Retrospective chart review was performed to assess rates of primary wound healing, complications, recurrence, and incontinence. Recurrences were grouped into three types: type I, sinus tract or recurrent abscess without an internal opening; type II, conversion to an intersphincteric fistula; and type III, transsphincteric recurrence.

Results: The majority of patients were male (69%) with a mean age of 44 years and mean BMI 31.6 kg/m². Median operative time was 88 min. Primary healing rate was 94%. Median healing period was 7 (range 4-16) weeks. Of the 10 recurrences, (5 type I, 5 type II, and 0 type III), median time to recurrence was 6 months after the primary wound healed. No patients experienced any postoperative incontinence or urinary retention.

Conclusions: In this cohort of patients with transsphincteric fistulas undergoing the LIFT procedure, the addition of offsetting muscle plication effectively limited transsphincteric recurrence. Further investigation is warranted to directly compare this LIFT adaptation to previously published literature.