Rectal washout eliminates exfoliated malignant cells

PURPOSE: Irrigation of the rectal stump before anastomosis after resection for carcinoma is accepted colorectal surgical practice. However, not all surgeons perform this routinely, and it has never been established conclusively that irrigation of the rectal stump eliminates exfoliated malignant cells or even reduces local recurrence. The patients of a surgeon whose standard surgical practice involved rectal irrigation were compared with those of a surgeon who does not routinely practice rectal irrigation. METHOD: Ten patients were given rectal washout with 200 to 500 ml of normal saline introduced via a Foley catheter per rectum. Ten patients were not given rectal washout. In both groups the anastomosis was performed with a circular stapler, and the stapler and donuts were rinsed in 200 ml of normal saline. The saline was sent for cytologic examination and classified as malignant cells seen or no malignant cells seen. The cytopathologist was blinded to the washout status. RESULTS: Of the ten patients who had rectal washout performed, none had malignant cells seen. Of the ten patients who did not have rectal washout performed, eight had malignant cells seen in the cytology (P = 0.007; two-tailed Fisher's exact probability test). CONCLUSION: Rectal washout eliminates exfoliated malignant cells in the rectum in the vicinity of the anastomosis.     

A modification of single stapled colorectal anastomosis using the transanal insertion device (TAIS)

A modification of single stapled colorectal anastomosis utilizing a reusable stapler head (transanal insertion device [TAIS]) is described. This modification minimizes the time that the proximal bowel is open by allowing early placement of the circular stapler head, and minimizes the risk of rectal injury that may be associated with the passage of a circular stapling device without the head in situ.     

Assessment of dysplasia, mucosal mucins, p53 protein expression, and DNA content in ulcerative colitis patients with colectomy and ileorectal anastomosis

BACKGROUND: Patients with ileorectal anastomosis after colectomy for ulcerative colitis remain at risk of developing rectal malignancy. Detection of mucosal dysplasia has been used for regular screening but is difficult in inflammatory mucosa, prompting the search for complementary markers. METHODS: This prospective study aimed to assess the prevalence of dysplasia, the predominance of sialomucin, DNA aneuploidy, and p53 overexpression as possible predictors of colorectal tumourigenesis, in the rectal mucosa of an unselected group of 27 patients with ileorectal anastomosis performed for ulcerative colitis. Patients had neither neoplastic nor dysplastic lesions on the colectomy specimen and the retained rectum at the time of surgery. One biopsy specimen of each lateral rectal wall was studied, using routine histology, mucin histochemistry, DNA flow cytometry, and the streptavidin-biotin complex method with D07 monoclonal antibodies directed towards the p53 protein. RESULTS: Seventeen, seven, and three patients showed inflammatory lesions of inactive, moderate, and severe active colitis, respectively. Dysplasia, sialomucin predominance, DNA aneuploidy, and p53 overexpression were not detected. CONCLUSIONS: The risk of malignant transformation of the rectal mucosa after ileorectal anastomosis seemed to be low in this ulcerative colitis group without high-grade dysplasia or carcinoma in the previous colectomy specimen, carefully followed up endoscopically and histologically. It remains to be evaluated which of the methods studied above will optimize the histopathologic surveillance of the rectal mucosa of ulcerative colitis patients with ileorectal anastomosis.     

Laparoscopic colo-rectal surgery

Laparoscopic colorectal surgery was less invasive for patients although it was difficult to perform complete resection of colon combined with regional lymph node. The skillful manner of the laparoscopic surgery was required for the surgical team. The laparoscopic equipments, in order to perform curative dissection of mesenterium and intermediate lymph node, such as Ultrasonic-aspiration surgical unit (USU) or Harmonic scalpel laparoscopic coagulation shears (LCS), were useful for safer dissection of D2 regional lymph node. Meticulous manner of grasping forceps and special dissectors was made sufficient lymph node dissection. The reconstruction of extracorporeal anastomotic technique by hand or valtrac (biofragmentable anastomosis ring) were safer manner for anastomosis after resection of the right side colon. Reconstruction by double stapling technique of linear stapler and circular stapler was admired for anastomosis for left side colonic and rectal surgery. We had safely performed locar resection in 3, partial resection with Do dissection in 2, with D1 dissection in 14, with D2 dissection in 21 and right and left hemicolectomy in 1 each.     

Endoscopic treatment of postoperative hemorrhage from a stapled colorectal anastomosis

We present the sixth reported case of endoscopic electrocoagulation to successfully treat postoperative hemorrhage from a stapled colorectal anastomosis. A literature review revealed 17 patients with postoperative hemorrhage from a combined total of 775 patients (1.8 per cent) after stapled colorectal anastomosis requiring blood transfusion and/or emergency surgery. Twelve of the 17 cases involved a circular stapler (71 per cent) used during an anastomosis to the rectum (69 per cent). Nonoperative therapy was successful in 14 of the 17 patients (82 per cent), using endoscopic electrocoagulation in six patients (43 per cent) and blood transfusion alone in another six patients (43 per cent). In follow-up there was one death (cardiac) and two anastomotic fistulas (one requiring temporary colostomy) in the nonoperative group. Both anastomotic fistulas occurred following hemorrhage from an anastomosis to the rectum using the circular stapler, one after endoscopic electrocoagulation and the second after blood transfusion alone. In summary, postoperative hemorrhage from a stapled colorectal anastomosis, although rare, is most likely to occur in a colorectal anastomosis constructed with the circular stapler. Nonoperative treatment is usually successful. Endoscopic electrocoagulation may be safely and effectively used in the early postoperative period to cease unremitting anastomotic hemorrhage.     

Anterior luxtasphincteric stapled rectumresection

BACKGROUND/AIMS: Sphincter saving deep anterior rectumresection improved the live quality of the rectal cancer patients. With the technical progress the resection level could be moved significant distally. The initial experiences are referred with the use of the stapler with flexible shaft in six patients operated due to very deep rectal cancer. METHODOLOGY: After the usual rectum mobilization the Proximate access AX55 mm (Ethicon) is positioned onto the stretched rectum. The flexible shaft has to be curved to the front and the jaw has to be angled parallel to the handle. The partially closed jaw of the stapler is then pushed towards the anus and then fired. The rectum is the resected. The operation is completed with EEA stapled anastomosis. RESULTS: Excellent results in all six patients could be noticed 3-18 months after the procedure. No cancer recurrence occurred. Functional sphincter investigation was performed in two patients with result of physiologic sphincter function. Stolen frequency has been stabilised between 2-8 a day. CONCLUSION: Improved transabdominal stapled method of rectum resection guarantees comfortable and oncologically safe resection of the distal rectum with maintenance of the sphincter function.     

Posterior sagittal resection for rectal aganglionosis: preliminary results of a new approach

BACKGROUND: There is no general agreement about how patients who have short-segment Hirschsprung's disease should be treated. METHODS: Ten patients with Hirschsprung's disease, seven with rectal and three with rectosigmoidal aganglionosis, were operated on through a posterior sagittal incision. In nine patients, a primary rectal resection and coloanal anastomosis was performed. In one patient, a longitudinal posterior myectomy of the rectum was performed as a primary procedure, but the procedure was eventually converted to a rectal resection and coloanal anastomosis through the same incision. RESULTS: One early and one late anastomotic complication occurred. Both were successfully treated with a temporary fecal diversion (left-sided colostomy for 6 to 8 weeks). The functional results as evaluated with anorectal manometry were similar to a group of Hirschsprung's patients treated with transabdominal pull-through resection and coloanal anastomosis. CONCLUSION: This approach might prove to be a useful alternative both to the transabdominal resection and the posterior longitudinal rectal myectomy in Hirschsprung's disease with rectal aganglionosis.     

Intracorporeal colorectal anastomosis following laparoscopic left colon resection

BACKGROUND: The aim of this study was to assess the impact of an intracorporeal double-stapled colorectal anastomosis upon the outcome of laparoscopic left colon resection. METHODS: Fifty-four selected patients underwent elective laparoscopic left colon resection for benign disease. Once resection was completed, a 33-mm suprapubic port allowed insertion of the anvil of a circular stapler into the colon, which was closed by a handsewn purse-string suture using the T-needle technique. The circular stapler was passed transanally to perform a double-stapled anastomosis. Specimens were delivered in a plastic bag via the suprapubic port. RESULTS: There were no deaths. Minor intraoperative and postoperative complications occurred in 3.7% and 9.2% of the patients, respectively. Median operating time was 125 min (range 80-210 min). Complete proximal and distal doughnuts were obtained in all patients and anastomoses were all methylene blue tight. Median hospital stay was 4 (range 3-7) days. CONCLUSIONS: Fashioning double-stapled colorectal anastomoses intracorporeally is feasable and safe.     

Colovaginal anastomosis: a unique complication of end-to-end anastomosis stapler use in low anterior resection

Anastomotic staplers have been used in colorectal surgery for several years. End-to-end stapler use for low anterior resection, as well as for other procedures, is common in surgical practice. These staplers have allowed more extended, lower resections of the colorectum without loss of bowel continuity or sphincter function. There have been reported complications of stapler use, with anastomotic stricture and leakage being the most common. We report here a unique complication of direct colovaginal anastomosis using the end-to-end stapler during a low anterior resection of an early-stage rectal adenocarcinoma.     

A new technique applicable to pediatric laparoscopic surgery: abdominal wall 'area lifting' with subcutaneous wiring

BACKGROUND: Recently, the authors developed a unique method of laparoscopic surgery without pneumoperitoneum: "area lifting of the abdominal wall with subcutaneous wiring." METHODS: In this gasless procedure, the anterior abdominal wall is pulled upward by a pair of wires placed subcutaneously and held by thick sutures for "hanger lifting." Simultaneous lifting of a pair of subcutaneous wires across the abdomen, produces a wide, roof-shaped intraabdominal space sufficient for laparoscopic surgical procedures. The practical aspects of this gasless technique, as well as the authors' limited experience with this method in 24 children, ranging from 8 days to 15 years of age is presented. These children have had various pathologies including splenomegaly, rectal prolapse, ovarian cyst, gall stone, adrenal neuroblastoma, and abdominal wall abscess. CONCLUSIONS: Gasless laparoscopic surgery with double subcutaneous wiring is safe for children including neonates and those with respiratory compromise because all operative procedures are performed under normal abdominal pressure. Because of the highly elastic abdominal wall musculature inherent in children, this selective area lifting of abdominal wall creates a relatively larger peritoneal volume than in adults.     

Esophagogastrostomy with the EEA stapler

Esophagogastric anastomosis was performed with the EEA stapler in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels of the thoracic and cervical esophagus by a variety of approaches. Routine barium cine-esophagograms obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3% (1 of 31 patients). Technical problems occurred during the operation in three patients; in two of these an incomplete anastomosis may have resulted from the surgeon's error. All patients were able to swallow normally at the time of discharge. Late anastomotic stricture occurred in five patients, and responded to dilatation in all but one patient who had local tumor recurrence. We conclude that the EEA stapler allows rapid and reliable esophagogastric anastomosis. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls.     

Dilatation of the left colon with a Foley catheter: an aid to staple anastomosis

Balloon dilatation of the left colon using a Foley catheter was performed in 26 patients prior to staple anastomosis. A 28-mm stapler was then used in six (23%) patients, a 29-mm in seven (27%), a 31-mm in eleven (42%) and a 33-mm in two (8%). Two anastomoses failed (7.9%) and one patient developed local recurrence. None of the remainder developed a symptomatic stricture. Flexible sigmoidoscopy was performed on 18 patients at least 3 months after surgery, revealing that one (5.5%) had developed an asymptomatic stricture. A 28-mm stapler had been used in this case. This technique of dilating the left colon with a Foley catheter is a useful aid to staple anastomosis in large bowel surgery.     

Colorectal surgery using a biofragmentable anastomotic ring

To compare the efficacy of the biofragmentable anastomotic ring (Valtrac-BAR, Davis and Geck, Medical Device Division, Danbury, CT, USA) with conventional anastomotic techniques, 30 patients who underwent colorectal surgery from August 1993 to March 1995 were retrospectively studied. The use of the BAR was also compared with conventional techniques including hand-sewn sutures in 30 patients and an end-to-end anastomosis (EEA) stapler in 24 patients. There were 17 men and 13 women in the BAR group with ages ranging from 37 to 80 years, 18 men and 12 women in the hand-sewn group with ages ranging from 41 to 82 years and 14 men and 10 women in the EEA group with ages ranging from 38 to 72 years. Surgical indications included: 25 colon cancers and five rectal cancers in the BAR group; 27 colon cancers and three rectal cancers in the hand-sewn group; and six colon cancers and 18 rectal cancers in the EEA group. There was no conversion to other anastomotic methods. Most of the patients tolerated a low-residual diet from the fifth post-operative day. No clinical leakage or stricture was noted. Only seven patients were aware of the passage of BAR fragments. The mean hospital stay was 14.1 days. There were no significant differences among these techniques in the return of bowel function, the incidence of surgical complications, including anastomotic leakage, or the length of hospitalization. BAR anastomosis was more time efficient than conventional techniques. Our results confirmed that BAR was an ideal sutureless alternative for anastomosis in colorectal surgery.     

Anastomotic stenoses correlated with the use of mechanical staplers in the surgery of esophageal cancer

From 1990 to 1995, 187 patients underwent esophagectomy and esophagogastrostomy with the anastomosis performed inside the chest using a circular stapler. Twenty-three patients (12.3%) developed an anastomotic stricture. The incidence of anastomotic stricture was inversely related to the diameter of the stapler. Also concomitant cardiovascular diseases, morpho-functional disorders of the tubulized stomach (possible related to duodeno-gastric reflux) and neoadjuvant chemotherapy were recognized as significant risks factors. Endoscopic dilations were safe and effective in the treatment of anastomotic strictures.     

The prevalence and severity of cancer pain: a study of newly-diagnosed cancer patients in Taiwan

In current clinical practice the "double-stapling technique" is the standard for reanastomosis following minimally invasive sigmoid resection. In the present study, we compared the TESA technique (transient endoluminally stented anastomosis) with conventional stapled anastomosis and evaluated the effect of remnant foreign material on follow-up examination with endosonography. Laparoscopic sigmoid resection was performed in 12 pigs (mean weight 63+/-5.9 kg). Animals were randomly divided into two groups: In Group A, reanastomosis was performed following a standard technique using a 29-mm circular stapler. In Group B, the TESA technique using a resorbable radiopaque stent of polyglycolic acid was applied. The anastomosis was examined by plain x-ray on days 1, 7, and 14, and by contrast enema on day 42, respectively. Endosonography, macroscopic inspection, and histological evaluation of the anastomosis were performed on day 42. All anastomoses in group A were patent. In one animal in Group B stent displacement with subsequent leak of the anastomosis was observed. Circumferential length of the anastomosis on day 42 did not differ between the groups (Group A: 8.00+/-0.45 cm vs. Group B: 7.8+/-2.0 cm, p = 0.82). The duration of the operation was 130+/-27 minutes in Group A and 100+/-18 minutes in Group B (p = 0.06). Weight gain was equal: Group A: 24+/-9.6 kg vs. Group B: 24+/-5.0 kg, p = 0.74. Endosonography on day 42 postoperatively in the area of the anastomosis in group A was impaired due to metallic staples. TESA is a competitive method for reanastomosis following laparoscopic sigmoid resection. In contrast to the conventional technique, the anastomosis is free of foreign material 1 month after the operation, which facilitates follow-up examinations with endosonography as well as other imaging diagnostics.     

Axillary reduction mammaplasty--Yhelda Felício''s technique

The jejunal interposition operation after resection of distal esophagus and cardia, designed by Merendino and Dilard, has not been widely employed until now. The complexity of the procedure, demanding high performance, and still unacceptable postoperative mortality, were limiting factors and a challenge for many surgeons. The aim of this paper is to present three modifications of the original technique, without changing the basic concept of the Merendino procedure. These modifications differ from the original technique in three main ways: the longer isoperistaltic jejunal segment, the terminolateral mechanical esophagojejuno anastomosis, and the placement of the lower jejunogastric anastomosis on the posterior wall of the stomach. This report comprises an experience in 29 patients operated on in period 1972 through 1995. There were two postoperative deaths and long-term results were excellent in all except one patient who had an ischemic stenosis of the transplanted jejunal segment. Despite this, the Merendino procedure, simplified by these modifications, deserves to be more frequently used in the treatment of undilatable or recurrent strictures and other benign lesions which require resection of the distal esophagus and cardia.     

Total colectomy with rectal mucosectomy and ileoanal anastomosis for chronic ulcerative colitis in children and young adults

Total colectomy with rectal mucosectomy and ileoanal anastomosis has been utilized as a sphincter-saving operation in young people with chronic ulcerative colitis. From 1977 to 1979, our section of pediatric surgery performed this procedure on 12 children and young adults with chronic ulcerative colitis, with encouraging results. All patients are alive and well, and all have had excellent rectal continence. Follow-up ranges from 7 to 27 months. Eight patients describe an excellent result, two have had a fair result, and two have required a temporary ileostomy. Numerous loose stools have been observed early, but stools become formed by diet and medical management, and early return to school and work has been possible. The number of stools continues to decrease for at least 1 year.     

Staged pull-through for rectosigmoid Hirschsprung's disease is not safer than primary pull-through

Conventional treatment of Hirschsprung's disease consists of initial colostomy followed by pull-through (staged PT). During the past decade immediate definitive operation (primary PT) has been reported by several investigators with a complication rate ranging from 0% to 20%. In the authors' institution primary PT has been performed since 1992 in patients with rectosigmoid aganglionosis responsive to rectal irrigations. The authors reviewed the records of all patients (n = 124) with Hirschsprung's disease diagnosed and treated between 1989 and 1995. One hundred sixteen patients underwent a definitive operation. This study analysed the complications observed in 87 of these patients with aganglionosis limited to the rectosigmoid colon. Patients were divided into groups according to the type of surgical treatment (staged versus primary), the year of operation (1989 through 1992 versus 1992 through 1995), and the age at primary PT (15 infants age < or = 4 months versus 10 children age > 4 months). There were no deaths. There was no significant difference in complication rates between staged PT and primary PT. Similar complication rates were encountered in infants and children who underwent primary PT. The rate of postoperative complications did not change according to the year of the operation. Major complications were observed in all 3 patients who had a primary Swenson PT compared with 20% who had a primary Duhamel PT. Staged Swenson and Duhamel PT had similar complication rates. The authors conclude that (1) staged PT for rectosigmoid Hirschsprung's disease is not any safer than primary PT; (2) primary PT can be performed safely in young infants; and (3) primary Swenson PT is less satisfactory than primary Duhamel PT.     

Chemical synthesis of D-ribo-phytosphingosine-1-phosphate, a potential modulator of cellular processes

OBJECTIVE: The nonpenetrating, arcuate-legged clip has proved its ability to provide a high-quality microvascular anastomosis. This study assessed the feasibility of constructing a coronary end-to-side anastomosis on the beating heart with a novel mechanical, sutureless anastomotic device that applies 12 circumferential clips simultaneously. METHODS: In 14 consecutive pigs (70-90 kg), the left internal thoracic artery (diameter, 3 mm) was grafted to the left anterior descending coronary artery (diameter, 3 mm) by means of a one-shot anastomotic stapler prototype. Endothelial denudation, medial necrosis, and intimal hyperplasia were analyzed quantitatively and compared with those seen in conventionally sutured anastomoses (n = 4). RESULTS: In 8 of 14 anastomoses, the one-shot anastomotic stapler successfully applied all 12 clips circumferentially across the everted arteriotomy edges. In the remaining, either 1 (n = 4) or 3 and 4 adjoining malaligned clips had to be replaced manually with a single-clip applicator. Coronary occlusion was limited to approximately 3 minutes. At follow-up, all anastomoses were patent angiographically. At 2 days, in 2 of 7 cases, a local coronary dissection was observed, and there was a considerable loss of endothelial cells and medial damage. At 28 days, however, minimal intimal hyperplasia was seen at the anastomotic lining, although more pronounced when compared with conventionally sutured anastomoses. CONCLUSIONS: The one-shot anastomotic stapler prototype enabled short-occlusive (3 minutes), sutureless end-to-side grafting on the beating porcine heart. In spite of early endothelial and medial damage and 2 local dissections, all anastomoses remained patent with minimal intimal hyperplasia at 4 weeks.     

Endoscopic Nd:YAG laser treatment of inoperable lower gastrointestinal cancer

Many patients with colorectal cancer are not amenable to curative resection at the time of presentation. Nevertheless, palliative resection still remains as the treatment of choice in the majority of patients. A small group of patients that are poor candidates for surgical resection may benefit from some non-surgical palliative procedures to relieve their symptoms. Electrocoagulation, cryosurgery and radiotherapy are some of the non-surgical procedure used and they are associated with high morbidity and mortality. The use of Neodymium: Yttrium-Aluminium-Garnet (Nd:YAG) laser photoablation to palliate patients with advanced colorectal carcinoma is well documented. It is associated with relatively low morbidity and perioperative mortality. It requires no anaesthesia and is the only non-surgical procedure that can be safely carried out above the peritoneal reflection. Nd:YAG laser had been used in some centres as a preresectional procedure in patient presenting with high grade obstruction. It allows proper bowel preparation followed by primary excision and anastomosis. As a palliative procedure, most patients showed rapid improvement in obstructive symptoms, bleeding and rectal discharge. The size of the lesion and circumferential extent of the tumour base correlate well with the response rate. Most patients remained asymptomatic before they succumb to the advanced disease. In our series, good palliation of obstructive symptoms was achieved in all obstructive cases with one laser treatment, bleeding tumours required an average of two sessions for complete haemostasis. In conclusion, Nd:YAG laser therapy is a safe and efficacious means for palliation of obstructive symptoms and bleeding in advanced rectal carcinoma.