Techniques in Coloproctology最新文献

Background and aims: Unsuccessful first-line conservative treatments for managing fecal incontinence (FI) lead to considering predominantly invasive options, posing challenges in terms of cost and patient acceptance of benefit/risk ratio. Recent data from a prospective randomized study have highlighted intramural rectal botulinum toxin (BoNT/A) injection as a promising minimally invasive alternative for urge FI, demonstrating efficacy at 3 months but lacking long-term evidence. This study aimed to evaluate the sustained efficacy and injection frequency of intramural rectal BoNT/A injection in the treatment of urge FI.

Methods: This retrospective monocentric study enrolled all patients who underwent intramural rectal BoNT/A injection for urge FI after failed conservative therapy or sacral neuromodulation (SNM). Injections were administered during sigmoidoscopy, delivering 200 U of BoNT/A at 10 circumferentially distributed sites. Treatment effectiveness was assessed using the Cleveland clinic incontinence score (CCS) and a visual analog scale (VAS) to measure the severity of discomfort related to episodes of fecal urgency, with reinjection performed upon symptom recurrence.

Results: In total, 41 patients (34 females) were included, with a median follow-up of 24.9 (range 3.2-70.3) months. Overall, 11 patients had previously failed sacral nerve stimulation. Significant reductions were observed in the CCS (median 11 versus 7, p = 0.001) and VAS symptoms (median 4, range 0-5 versus median 2, range 0-5, p = 0.001). In total, 22 patients (53%) experienced a reduction in the CCS by over 50%. The median interval between intramural rectal BoNT/A injections was 9.8 months (range 5.3-47.9 months).

Conclusions: This study provides the first evidence of the sustained efficacy of intramural rectal BoNT/A injection for urge FI. Further investigations are warranted to refine patient selection and reinjection criteria, evaluate socioeconomic impacts, and compare rectal BoNT/A injection with other therapeutic modalities.

Background: This study aimed to evaluate the risk factors associated with rectal perforation during various surgical interventions for presacral cysts.

Methods: This retrospective study included 73 participants from 2013 to 2023 who met the inclusion criteria. Participants underwent surgical treatments through transabdominal, perineal, or combined approaches. Preoperative assessments of presacral cysts were performed using computed tomography (CT) and magnetic resonance imaging (MRI). Biannual postoperative follow-ups involved ultrasound, CT, or MRI scans. Data analysis was conducted using RStudio software.

Results: The incidence of rectal perforation did not differ significantly across surgical approaches [combined 2 (18%) vs. perineal 3 (8.8%) vs. transabdominal 4 (14%), P = 0.7]. Cyst capsule rupture was more frequent in the transabdominal and combined approaches [17 (61%) and 5 (45%), respectively] versus perineal approach [8 (24%), P = 0.011]. The laparoscopic subgroup experienced a higher rate of cyst rupture compared to the robotic subgroup, with rectum perforation cases only correlating with ruptures in the robotic subgroup. Intraoperative complications prompted conversions to open surgery in the laparoscopic group, unlike in the robotic group. Postoperative follow-up revealed no mortalities, with malignant transformation observed in two cases and local recurrences in three. While univariate analysis did not identify significant predictors of rectal wall perforation, multivariate analysis suggested that the risk of perforation increased with cyst rupture and decreased when the cyst was located further from the anal verge.

Conclusions: The study identifies two primary risk factors for rectal wall perforation: the cyst capsule integrity and the cyst-rectum shortest distance, with the latter being accurately determined by MRI. These findings may inform further surgical planning and risk assessment.

Background: Transanal total mesorectal excision (TaTME) is a promising and innovative approach for lower rectal cancer but requires high technical skill and learning process that can affect patient outcomes. We aimed to determine the learning curve of TaTME and then to assess its impact on 5-year oncologic outcomes.

Methods: Over a 54-month period, 94 patients underwent TaTME by experienced laparoscopic colorectal surgeons at our department. To provide a comprehensive overview of success, we used a composite criterion including the most relevant parameters related to the learning process: the conversion rate to an open procedure, TaTME procedure completion, severe postoperative morbidity, mesorectal integrity on macroscopic evaluation, and microscopic margins. Moving average method and cumulative sum analyses were performed.

Results: The operative time continuously decreased over the entire study period. The success rate stabilised after 14 patients in a parallel and balanced analysis of the two surgeons' experiences. Mesorectal completeness was the most sensitive marker for the TaTME learning process (42.9% vs 71.25%; p = 0.06). The learning process did not significantly affect the postoperative morbidity, conversion rate, or R0 resection. Five-year oncological outcomes were similar between the groups.

Conclusion: Even among laparoscopically experienced surgeons, the TaTME learning process influences the oncological quality of the resection but not the postoperative morbidity. Gaining an early command of the surgical anatomy and technical skills and understanding the challenges through specific educational sessions are necessary. The results of this study could help generate a comprehensive training program and define necessary prerequisites for prospective trials.

Trial registration: This study is registered in our Clinical Research Unit (2016_LELONG_01). Our database is registered in the clinicalTrials.gov registry: Institut Paoli Calmettes Colorectal Cancer Database (NCT02869503).

Background: This study aimed to investigate the utility of minimally invasive sinus laser therapy (SiLaT) versus flap surgery (Karydakis flap procedure) in terms of intraoperative parameters and postoperative outcome in patients with pilonidal sinus disease (PSD).

Methods: A total of 106 patients with PSD (mean ± SD age: 26.4 ± 7.0 years, 86.8% male) treated with Karydakis flap procedure (KF group; n = 63) or sinus laser therapy (SiLaT group; n = 43) were included in this retrospective study. Data on patient demographics, operative characteristics (number of openings, length of sinus tract, and operative time), and postoperative outcome including postoperative (day 1) pain intensity-visual analog scale (VAS) scores, time to return to work after surgery (days), complication rate, and recurrence rate were recorded in each patient and compared between KF and SiLaT groups.

Results: The SiLaT versus KF procedure was associated with significantly shorter operative time [median (min-max) 17 (12-28) versus 27 (20-44) min, p = 0.001], lower pain scores [3 (1-4) versus 5 (3-7), p = 0.001], and earlier return to work [1 (1-3) versus 10 (5-20) days, p = 0.001]. Although no significant difference was noted in complication and recurrence rates between the KF and SiLaT groups, 6.3% (wound infection only) and 3.2% of patients in the KF group but none of the patients in the SiLaT group developed complication and recurrence, respectively.

Conclusions: SiLaT seems to be a promising minimally invasive technique for the management of PSD, being comparable to the KF procedure in terms of complications and recurrence, along with added advantages of shorter operative time, reduced postoperative pain, and earlier return to work.

Effective closure of both muscular and mucosal defects after endoscopic submucosal dissection (ESD) remains a technical challenge. Failure to adequately address such defects may increase the risk of delayed perforation. In this video case report, we demonstrate the application of the through-the-scope (TTS) tack system for defect closure following ESD in a patient with a cecal lesion. The patient, a 79-year-old male, presented with a 75-mm laterally spreading sessile lesion in the cecum identified during screening colonoscopy. ESD was performed successfully, revealing a partial defect in the muscular layer. To address the risk of complications associated with this defect, we utilized the X-Tack™ endoscopic heliX tacking system (Apollo Endosurgery, Inc., Austin, TX, USA) to achieve secure closure of both the mucosal and muscular layers. The procedure was completed without complications, and the patient was discharged on the same day. This case highlights the feasibility and safety of the TTS tack system for the closure of combined mucosal and muscular defects after ESD, particularly for right-sided colonic lesions.

Background: This study aimed to evaluate the use of 3D image processing and reconstruction (3D-IPR) combined with virtual reality (VR) technology and printed models (PM) as teaching tools in oncological colorectal surgery.

Methods: We designed two courses, one for general surgery trainees and another for young colorectal surgeons, structured around stations of pre-test, anatomical lessons, real-case presentations, 3D-IPR models, VR experiences, and life-size abdominal PM with surgical approach explanations and a final post-test.

Results: Fourteen course participants were evaluated. Pre-test scores averaged 5.15, with a median of 5.5, while post-test scores increased to an average of 7.75, with a median score of 8. Course satisfaction surveys indicated high ratings for expectations, duration, relevance, presenter knowledge, teaching materials, communication, and overall course segments, with an average rating exceeding 4.8 out of 5. Results highlight the potential of 3D-IPR, VR, and PM as tools for improving teaching for surgery residents and colorectal surgeons. These technologies offer immersive, risk-free experiences for learners, potentially enhancing skill acquisition and anatomical understanding.

Conclusion: This study demonstrates the effectiveness of 3D-IPR, VR, and PM courses in improving understanding of colorectal surgery. As these technologies continue to advance, they offer enhanced immersion and accessibility, transforming surgical education and medical training.

Background: Bowel-preserving local resection of early rectal cancer is less successful if the tumor infiltrates the muscularis propria as opposed to submucosal infiltration only. Magnetic resonance imaging currently lacks the spatial resolution to provide a reliable estimation of the infiltration depth. Endoscopic ultrasound (EUS) has better resolution, but its interpretation is investigator dependent. We hypothesize that automated image segmentation of EUS could be a way to standardize EUS interpretation.

Methods: EUS media and outcome data were collected prospectively. Based on 373 expert manual segmentations, a convolutional neural network was developed to perform segmentation of the submucosa, muscularis propria, and tumors. The mean surface distance (MSD), maximal distance between segmentations (Hausdorff distance; HDD), and overlap (Dice similarity index; DSI) were calculated.

Results: The median MSD and HDD values were 3.2 and 17.7 pixels for the tumor, 3.4 and 24.7 pixels for the submucosa, and 2.6 and 20.0 pixels for the muscularis propria, respectively. The median DSI values for the tumor, submucosa, and muscularis propria were 0.82, 0.57, and 0.59, respectively. These values reflect good agreement between manual and deep learning segmentation.

Conclusions: This study found encouraging results of using automated analysis of EUS images of early rectal cancer, supporting further exploration in clinical practice.

Background: Diverticulitis has significantly increased in prevalence in recent decades, requiring higher rates of colon resections. While current literature focuses on postoperative complications such as abscesses, wound infections, and anastomotic leaks, many are limited in showing details regarding the significant risk associated with developing renal insufficiency among diverticulitis patients undergoing colectomy.

Methods: We selected patients from the 2022 National Surgical Quality Improvement Program (NSQIP) Colectomy database who underwent colon resection for diverticulitis using International Classification of Disease (ICD10) code K57.92. To analyze postoperative renal function, we removed all patients with preoperative renal failure. From there, a total of 6985 patients with no postoperative renal insufficiency (Control group) and 492 with postoperative renal insufficiency (Post-op. RI group) were identified.

Results: Of individuals undergoing colectomy for diverticulitis, 6.58% experienced postoperative renal insufficiency. In all diverticulitis colectomies, comorbidities such as diabetes (21.95% versus 10.95%; p = 0.018), congestive heart failure (11.59% versus 2.95% p < 0.001), hypertension (61.79% versus 42.83%; p < 0.001), and chronic obstructive pulmonary disease (9.96% versus 3.66%; p < 0.001) were associated with higher risk of kidney injury. Multivariate regression analysis indicated that postoperative renal insufficiency is independently associated with increased risk of mortality (odds ratio = 3.8001; p < 0.001).

Conclusions: As the prevalence of diverticulitis has increased in the USA, it is paramount to recognize the risks associated with the required operation as well as the factors that affect patient outcomes and risks for developing renal insufficiency.

Introduction: Despite spectacular visuals and the seemingly convincing rationale of using indocyanine-green-enhanced fluorescence in assessing bowel perfusion during colorectal resections, a lingering sense of subjectivity remains in the challenge of quantifying this fluorescence. This prospective study analyzed the application of O2C® spectrophotometry to quantify zones of fluorescence on the large bowel during low anterior resection.

Materials and methods: Patients receiving a low anterior resection for cancer of the mid- and lower rectum were enrolled in this observational prospective study between February 2020 and December 2022. O2C® blood-flow measurement was performed at three different zones of fluorescence intensity (optimal [O], sufficient [S], and absent [A]), visualized at the designated and already skeletonized site of colon transection. The primary end point was to assess whether the O2C® flow value exceeds 164 arbitrary units (AU) at the zone of optimal fluorescence. The secondary objective was to assess whether there were statistically significant differences in flow parameters between the three zones, thus confirming reproducibility of measurements.

Results: A total of 40 patients were enrolled in this study. Of these, 38 patients remained for statistical analysis with regard to O2C® measurement of the fluorescence zones. The O2C® flow parameter measured at the zone of optimal fluorescence was greater than 164 AU in all cases (100%, p < 0.0001). There were statistically significant differences in flow parameters measured at the three different zones of fluorescence (O-S: p < 0.0001; O-A: p < 0.0001; S-A: p = 0.0023).

Conclusion: This study proves the feasibility and reproducibility of quantifying zones of indocyanine green (ICG)-enhanced fluorescence on the bowel. All O2C® flow measurements that were collected at the zone of optimal fluorescence exceeded 164 AU, thereby adding more evidence to this value as a suggested cut-off parameter in terms of bowel perfusion.