1,721,149 research outputs found
Surgical Treatment of Ulcerative Colitis: Laparoscopy and New Minimally Invasive Techniques
No full textNo Abstrac
Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn's disease a risk factor for failure? A prospective cohort study
No full textBACKGROUND:
The surgical management of rectovaginal fistulae associated with Crohn's disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn's-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn's disease patients and in a control group.
MATERIALS AND METHODS:
All patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005-2016). The primary study outcome was the comparison of the success rate of GMT in Crohn's disease and control group patients.
RESULTS:
Twenty-one patients with a rectovaginal fistula due to Crohn's disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57 months (p 0.34), the success rate of GMT was 75% in patients with Crohn's disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5 months (1-12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1).
CONCLUSION:
GMT is associated with a high success rate, especially in Crohn's disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae
Emergency Surgery in Obese Patients
No full textObesity is considered an important risk factor for the development of gastrointestinal
disorders [1], likely through alterations of gastrointestinal motility. Even though
gastroesophageal reflux disease is the condition mainly studied at present, the prevalence
of other upper gastrointestinal symptoms has also increased.
Upper gastrointestinal tract perforations occur as a result of various causes. The
majority of the perforations that we see today in the esophagus are iatrogenic (about
60%), but they could be spontaneous (Boerhaave’s syndrome), traumatic or due to
other causes. Perforation of a peptic, gastric or duodenal, ulcer is now less frequent
because of the availability of adequate medical therapy. Peptic ulcer disease represented
1% of the discharge diagnosis of patients with a body mass index
(BMI) > 25 kg/m2 admitted to the Surgical Unit of Christchurch Hospital, New
Zealand in a 26-month study period [2], and a surgical intervention for perforated
viscus accounted for 4.4% of patients with a BMI > 30 kg/m2 operated on at a US
community teaching hospital in 1 year [3].
They represent a surgical emergency and the timing of the intervention is very
important. Just one day of delay increases mortality significantly.
Since a detailed discussion of upper gastrointestinal perforations is beyond the
scope of this chapter, attention has been directed to examining the peculiar characteristics
of this topic in the obese population
Prospective Interventional Study to Evaluate the Effect of a Medical Device Made of Substances in Reducing Signs and Symptoms in Patients with Hemorrhoidal Disease
Full text linkBackground and Aim: Hemorrhoidal Disease (HD) is a chronic pathology and is fairly common in the general population. For this reason, conservative therapies need to be at the same time effective and tolerated. The topical medications available usually contain either a combination of local anesthetics with anti‐inflammatories or muscle relaxants, thus addressing a single mechanism, if any, of those that underlie symptoms onset. As
a consequence, evidence of efficacy of these drugs is currently limited and the needed tolerability and safety from a topical treatment of HD is not always evident. The aim of the present study was to evaluate efficacy and tolerability of a 100% natural ointment, a medical device made of substances, for the symptomatic treatment of HD.
Methods: Symptomatic grade I or II HD patients with 0-100 VAS score for HD-related discomfort ≥ 30 were treated for 10 days. Outcome measures included variation of HD subjective symptoms (discomfort, pain, itching and burning) and objective signs (bleeding and anal leakage) at day 3, 7 and 10, and the presence of prolapse after treatment.
Statistical analysis: for the analysis of the primary endpoint (i.e. reduction of discomfort), missing data in the full analysis set (FAS) population were replaced using the “Last Observation Carried Forward” (LOCF) method. For the analyses of secondary endpoints, Poisson mixed model was used to evaluate symptom variation (VAS). Bleeding and anal leakage were recoded as negative or positive in two different variables (grade 1 and 2) derived from
their frequency (i.e., for grade1, each of the clinical signs was considered Negative if the patient reported frequency was “Never”; recoded as Positive if any other frequency category was reported) and frequencies of positive patients in each grade were compared by Logistic Mixed model. Mixed models were used to take in account repeated data for the same subject. Missing values in quantitative data analysing by Mixed model were imputed by statistical interpolation. In analysing bleeding, anal leakage and presence of prolapse in FAS population, missing data where either replaced using the LOCF method or imputed as positive (i.e., worst case).
Results: 45 patients were enrolled. Data showed a significant reduction of discomfort in treated patients both during and after treatment (p<0.001 at all-time points evaluated), with a median VAS score decrease of 30 points after treatment when compared to baseline.
The same significant reduction (p<0.001) was shown for all other symptoms either at the end of treatment or at earlier time points, both in PP and FAS populations. As for objective signs, a significant reduction was observed, at each time point compared to baseline, in the number of patients from the PP population positive for bleeding (p<0.001) and anal leakage (p<0.05).
A similar evolution was shown in FAS population, where reduction was progressive over the 10-day treatment and statistically significant or almost significant irrespectively of imputation method used. In 6 out of 10 patients presenting prolapse at baseline, prolapse was no more evident after treatment. No treatment-related adverse events were registered.
Conclusion: The class IIb medical device made of substances under study is a valid, highly tolerated and safe therapeutic option in medical management of grade I and II HD. Trial registration NCT03545724 2018.06.04
Outcomes of pelvic exenteration for recurrent and primary locally advanced rectal cancer
No full textBackground Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center. Materials and methods This was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fisher's exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups. Results Since 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044). Conclusion The long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins
Rectovaginal fistula: Risk factors for failure after graciloplasty—A bicentric retrospective European study of 61 patients
No full textBACKGROUND: Graciloplasty (GP) is indicated in case of recurrent rectovaginal fistula (RVF) after failure of previous local treatments. The aim of this study was to assess risk factors for GP failure performed for RVF.METHODS: Retrospective study based on a prospective database of GP, coming from two expert centers.RESULTS: 61 patients undergoing a first GP for RVF (n=51) or ileal-vaginal fistula after ileal-pouch-anal-anastomosis (IPAA) (n=10), with a mean age of 42 years (range, 24-72) were analyzed. After a mean follow-up of 56 ± 48 months (range, 1-183), failure of GP (considered as persistent stoma and/or clinical RVF) was noted in 24/61 patients (39%). Failure rate was 43% (13/30) in case of Crohn's disease, 38% (3/8) in case of ileal-vaginal fistula after IPAA for ulcerative colitis, 30% in case of obstetrical RVF (3/10), 33% in case of post radiotherapy RVF (1/3), and 40% for other causes (4/10) (NS). Two risk factors for failure of GP were found on univariate analysis: 1) absence of postoperative antibiotic prophylaxis (PAP): only 3/24 (13%) patients with failure of GP received PAP versus 18/37 (49%) patients with success of GP (p=0.0053); 2) postoperative perineal infection: 11/23 (48%) with failure of GP failure developed postoperative perineal infection versus only 4/37 (10%) patients with success of GP (p=0.0021).CONCLUSIONS: Failure of Graciloplasty for rectovaginal fistula is observed in approximately 40% of the patients whatever the aetiology of the fistula. Reduced failure rate was associated with systematic postoperative antibiotic prophylaxis
A prospective analysis of the postoperative and long-term functional outcomes of a novel technique to perform rectal transection during laparoscopic restorative proctectomy and ileal pouch-anal anastomosis
No full textBackground: Laparoscopic ileal pouch-anal anastomosis (IPAA) technique is not standardized. An irregular division of the rectum could result in poor functional outcomes and residual diseased mucosa. The aim of the study was to develop a new technique for performing the rectal transection via a laparoscopic approach, and to compare the outcomes of this technique with those of the open surgery IPAA. Methods: This prospective study included all patients who underwent restorative proctectomy (following a previous subtotal colectomy) for ulcerative colitis in October 2017-November 2020. Rectal division was performed using a 30 mm open linear stapler which was applied laparoscopically across the distal rectum. Postoperative and functional outcomes, length of anal stump and completeness of mucosal removal were compared. Only the patients who had their ileostomy reversed by 31 December 2020 and, therefore, a minimum follow-up of 6 months from the ileostomy closure, were included in the analysis of the functional outcomes and quality of life. Results: There were 207 patients (161 laparoscopic, 46 open). Median age was 43 (18-77) years and 85 patients (41.1%) were male. Major complications (9.3 vs. 8.7%, p = 0.89) including anastomotic leaks (3.7 vs 4.4%, p = 0.84) were similar after laparoscopic and open IPAA. Patients reported a comparable number of bowel movements during the day (6 vs. 7, p = 0.21) and at night (2 vs. 2, p = 0.66), and a similar rate of episodes of incontinence during the previous 6 months (3.7 vs. 4.3%, p = 0.75). The mean Cleveland Global Quality of Life score was also similar (0.79 vs. 0.74, p = 0.35). Conclusion: Our technique is safe and reproducible, and replicates the results of the open IPAA, while maintaining the advantages of minimally invasive surgery and avoiding any kind of anal manipulation which could result in poor long-term functional outcomes
Mesenteric lengthening during pouch surgery: technique and outcomes in a tertiary centre
No full textAnastomotic complications after ileal pouch-anal anastomosis (IPAA) are often associated with excessive tension and poor
blood supply. Carrying out a tension-free IPAA might prove difficult in a proportion of cases, especially if mucosectomy
and hand-sewn anastomosis are necessary. The aim of the study was to analyse the outcomes of mesenteric lengthening
in patients undergoing IPAA in a tertiary centre. Consecutive patients who required mesenteric lengthening during IPAA
surgery between 2000 and 2019 were retrospectively included. Short and long-term outcomes were analyzed. Chi square,
Fisher’s exact test and Wilcoxon rank sum test were used as appropriate. Kaplan–Meier analysis was carried out to report the
long-term rate of pouch failure. Some 131 patients (78 UC, three indeterminate colitis, 50 FAP) were included. The need for
mesenteric lengthening, due to short mesentery or intraoperative complications, was unpredictable in 15 patients. The rate
of surgical complications was 20.6%; eight patients required a reoperation, two of them experienced postoperative pouch
ischemia. After a median follow-up time of 9.4 years, the risk of pouch failure in FAP and UC patients was 7.2% and 13% at
10 years. Despite the indication to mucosectomy has been reducing over the years, mesenteric lengthening is still required
in a significant proportion of UC and FAP patients, also because of unforeseeable intraoperative conditions necessities
Outcomes of robotic surgery for inflammatory bowel disease using the Medtronic HugoTM Robotic-Assisted Surgical platform: a single center experience
Full text linkPurpose
The aim of the study was to compare the perioperative outcomes of patients affected by inflammatory bowel disease (IBD) who underwent surgery performed through laparoscopy or using the Medtronic HugoTM RAS.
Methods
This is a retrospective study from a prospectively maintained database comparing laparoscopic vs. robotic-assisted surgery for IBD from 01/11/2017 to 15/04/2024. All procedures were performed by a single surgeon robotic-naïve with a large experience in laparoscopic surgery for IBD. The robotic procedures were performed using the Medtronic HugoTM RAS platform. Outcomes were 30-day postoperative complications, operative time, conversion rate, intraoperative complications, length of hospital stay, and readmission rate.
Results
Among 121 consecutive patients, 80 underwent laparoscopic (LG) and 41 robotic-assisted surgery (RG). Baseline, preoperative and disease-specific characteristics were comparable except for older age (50 [38–56] vs. 38 [28–54] years; p = 0.05) and higher albumin level (42 [40–44] vs. 40 [38–42] g/L, p = 0.006) in the RG. The intracorporeal anastomosis was more frequent in the RG (80% vs. 6%; p < 0.001) with longer operative time (240 vs. 205 min; p = 0.006), while the conversion rate was not different (5% vs. 10%, p = 0.49). Surgical procedure types were equally distributed between the two groups, and the rate of intra-abdominal septic complication (IASC) was comparable across the different procedures. Postoperative complications were similar, including the rate of IASC (5% vs. 5%, p = 1), postoperative ileus (5% vs. 7.5%, p = 0.71), bleeding (2% vs. 5%, p = 0.66), and Clavien-Dindo > 2 complications (7% vs. 6%; p = 1).
Conclusion
IBD surgery performed using the Medtronic HugoTM RAS is safe and feasible, with similar postoperative outcomes when compared to the laparoscopic approach
Morbidity associated with closure of ileostomy after a three-stage ileal pouch-anal anastomosis
No full textThe aim of the study was to compare the perioperative outcomes of patients undergoing ileostomy closure after a three-stage ileal pouch-anal anastomosis to a control group of patients who had elective colorectal resections and stoma, and to analyse the differences based on the technique of closure. The cases were retrospectively compared for demographic characteristics and postoperative outcomes. Chi-square, Fisher's exact and Wilcoxon rank sum tests were used as appropriate. Between 2011 and 2016, 338 patients having their stoma reversed after three-stage IPAA were compared to 158 patients in the control group. A younger age (43.2 vs 60.6 years, p < 0.0001), a lower body mass index (22 vs 24.4 kg/m2, p < 0.0001), a higher rate of hand-sewn anastomosis (84.3 vs 15.7%, p < 0.0001), a lower rate of intraoperative complications (0 vs 1.2%, p = 0.038), a shorter operative time (91.5 vs 99.4 min, p = 0.0046) and length of hospital stay (6.6 vs 7.6 days, p = 0.045) were seen in the IPAA group. The 30-day rate of wound infection, anastomotic leak (0.6 vs 0.6%), small bowel obstruction (SBO, 8 vs 11.4%) and reoperation (1.8 vs 1.3%) was similar. Among IPAA patients, the hand-sewn anastomosis was correlated with a higher chance of developing SBO (9.1 vs 1.9%, p = 0.03). Closure of ileostomy after three-stage IPAA is associated with low rate of serious complications, despite the higher number of previous abdominal surgeries. This supports the construction of routine ileostomy during IPAA to reduce the risk of pelvic sepsis
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