Feasibility of endoscopic hand suturing on rectal anastomoses in ex vivo porcine models

Prevention of postoperative anastomotic leakage in rectal surgery is still required. This study investigated the feasibility of endoscopic hand suturing (EHS) on rectal anastomosis ex vivo. By using isolated porcine colon, we prepared ten anastomoses 6–10 cm from the virtual anus. Then, we sutured anastomoses intraluminally by EHS, which involved a continuous suturing method in 5 cases and a nodule suturing method with extra corporeal ligation in 5 cases. Completeness of suturing, number of stitches, procedure time and presence of stenosis were investigated. Furthermore, the degree of stenosis was compared between the two suturing methods. In all cases, EHS were successfully completed. The median number of stitches and procedure time was 8 and 5.8 min, respectively. Stenosis was created in all continuous suturing cases whereas none was seen in nodule suturing cases. The shortening rate was significantly greater in the continuous suturing method than in the nodule suturing method. Intraluminal reinforcement of rectal anastomosis by EHS using nodule suturing with extra corporeal ligation is feasible without stenosis, which may be helpful as a countermeasure against possible postoperative anastomotic leakage in rectal surgery.

A New Approach for Pelvic Tumors Invading the Rectum

Objective: Sometimes pelvic tumors invade the rectal wall, needing removal Design: An alternative technique of radical/conservative surgery (trying to preserve as much as possible the muscular complex) is presented, inspired by De La Torre treatment of Hirschprung’s disease. The lower rectum is only partially resected on the non-involved side, where only mucosa is removed, followed by a lower end to end rectal anastomosis Results: Normal defecation Conclusion: A good surgical alternative

Revising Our Concepts about Stoma Covering a Low Rectal Anastomosis

Introduction There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However, whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis. Objective To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma. Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure. Results We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups. Conclusion and Recommendation Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis.

Rectovaginal fistula: An early complication of radiotherapy in a sexagenarian with cervical cancer

A 62-year-old Nigerian woman was admitted on account of cervical carcinoma Stage IV and was requested to undergo radiotherapy and chemotherapy. Six weeks after commencing this treatment she starting passing feces involuntarily through the vagina. Imaging studies revealed a high sited, medium sized, and rectovaginal fistula (RVF). RVFs have been documented as a late complication of radiotherapy for any gynecological malignancy but it occurred earlier in this patient. A preliminary surgical procedure, a sigmoid-ostomy, was performed successfully and a definitive surgery, a sigmoido-rectal anastomosis, was planned to be done in 18 months after the diagnosis of the RVF but the patient died shortly after the first procedure. The present case indicates that a RVF can occur as an early complication of radiotherapy even when it presents with mild symptoms.

DOP33 Predictors of ileo-rectal anastomosis, permanent ileostomy and recurrence of disease after total colectomy for Crohn’s Colitis: Results over 20 years

Background Patients with surgical Crohn’s colitis (CC) might either undergo a total colectomy (TC) and ileo-rectal anastomosis (IRA), or TC and end ileostomy. Among the latter group, a second-stage IRA is not always performed. The predictors of the different outcomes after TC (including the recurrence of disease at the level of the anastomosis) are yet to be identified. Methods Retrospective study including 354 patients undergoing TC for CC (2000–2019), with a minimum preoperative follow-up of 2 years in our centre. The mean postoperative follow-up was 67.5+/-49.8 months (62 patients lost). The primary end-points were to identify the predictors for the following outcomes: a) IRA (87 cases, 24.6%) vs. end ileostomy (267 cases, 75.4%) at the primary colectomy. b) second-stage IRA (80 cases, 39%) vs. no IRA (125 cases, 61%) at the last follow-up. c) recurrence of the disease after IRA (167 patients). Considering the large number of regressors and the risk of over-fitting, the least absolute shrinkage and selection operator (LASSO) method was used. A multivariate analysis was carried out using the preselected covariates. The analysis was conducted using logistic regression and cox regression for dichotomus and time-dependent outcomes. A p-value<0.05 was considered significant. Results a) Predictors against the IRA at primary TC: preoperative biologic exposure (OR=1.96, CI 1.15–3.33, p=0.014), Crohn’s rectal location (OR=4.17, CI 2.0–8.33, p<0.0001), perianal disease (OR=3.33, CI 1.75–6.25, p<0.0001), and low hemoglobin concentration (OR=1.26, CI 1.01–1.58, p=0.037). b) Predictors of the risk of still having the ileostomy at the follow-up: age (OR: 1.02, CI 1.00–1.04, p=0.045), exposure to biologics before (OR 1.85, CI 1.11–3.03, p=0.017) and after (OR 1.79, CI 1.11–2.89, p=0.018) the TC; postoperative use of azathioprine was associated with a greater chance of a second-stage IRA (OR 2.66, CI 1.21–5.83, p=0.014). c) Risk of anastomotic recurrence was 8.7% and 30.8% at 5 and 10 years. Significant predictors were: female gender (OR 2.38, CI 1.11–5.55, p=0.046), use of more than one biologic (OR 5.65, CI 2.18–9.89, p<0.0001) and worsening of symptoms needing for drug escalation (OR 5.51, CI 2.06–8.59, p=0.001) during the follow-up. Conclusion The location and severity of the disease at diagnosis predict the long-term behavior of the disease. The exposure to biologics, especially if multiple drugs are required, does not represent a risk for worse outcomes per se, but rather identifies a population at higher risk of permanent ileostomy due to more severe disease. These predictors might be implemented in the assessment of patients affected by CC, in order to identify the population at risk of permanent ileostomy.

Reinforcement of rectal anastomoses with a collagen-based haemostatic patch: a case series report

In this case series report of 10 colorectal cancer patients, a polyethylene glycol-coated collagen-based haemostatic patch was applied after rectal resection to reinforce rectal anastomoses and reduce anastomotic leakage. Patients underwent rectal resection and anastomoses were stapled in place. The patch—Hemopatch®—was applied to 75% of the anastomotic circumference. The surgeon judged the simplicity of application using a reinforcement of rectal anastomosis score. Mean age of patients was 68.1 (range 50–94) years. The patch was successfully applied in eight patients; in seven patients, patch application was straightforward or only slightly complex, according to the reinforcement of rectal anastomosis score. Seven of eight patients experienced no leakage or signs of stricture 6 weeks post-surgery. All patients underwent radical resection. It is possible to apply Hemopatch® during colorectal surgery. However, the patch application procedure needs to be standardized and efficacy needs to be evaluated by conducting larger clinical studies.