Surgery for obstructed defecation syndrome-is there an ideal technique

Obstructive defecation syndrome(ODS) is a common disorder with a considerable impact on the quality of life of affected patients.Surgery for ODS remains a challenging topic.There exists a great variety of operative techniques to treat patients with ODS.According to the surgeon's preference the approach can be transanal,transvaginal,transperineal or transabdominal.All techniques have its advantages and disadvantages.Notably,high evidence based studies are significantly lacking in literature,thus making accurate assessments difficult.Careful patient's selection is crucial to achieveoptimal functional results.It is mandatory to assess not only defecation disorders but also evaluate overall pelvic floor symptoms,such as fecal incontinence and urinary disorders for choosing an appropriate and tailored strategy.Radiological investigation is essential but may not explain complaints of every patient.

Surgical recurrence in Crohn's disease: Are we getting better?

Crohn's disease(CD) still remains a challenging chronic inflammatory disorder, both for colorectal surgeons and gastroenterologists. The need for recurrent surgery following primary intestinal resection is still considerable, though recent evidence suggested a declining rate of recurrence. Several conflicting surgical parameters have been identified that might impact on the postoperative outcome positively, such as access to the abdomen, anastomotic configuration or type of disease. Additionally, promising results have been achieved with the increased use of immunosuppressive medications in CD. Consequently, the question arises if we are getting better as a result of novel medical and surgical strategies.

Incidental adenocarcinoma in patients undergoing surgery for stricturing Crohn's disease

AIM To evaluate frequency and clinical course of incidental adenocarcinoma in patients with stricturing Crohn's disease(CD).METHODS In this study, consecutive patients, who were operated on for stricturing CD between 1997-2012, were included at an academic tertiary referral center. Demographic data and clinical course were obtained by an institutional database and individual chart review. Besides baseline characteristics, intraoperative findings and CD related history were also recorded. Colorectal cancer was classified and staged according to the Union for International Cancer Control(UICC).RESULTS During the study period 484 patients underwent resections due to stricturing CD. Incidental adenocarcinoma was histologically confirmed in 6(1.2%) patients(4 males, 2 females). Patients diagnosed with colorectal cancer had a median age of 43(27-66)years and a median history of CD of 16(7-36) years. Malignant lesions were found in the rectum(n = 4, 66.7%), descending colon(n = 1, 16.7%) and ileocolon(n = 1, 16.7%). According to the UICC classification two patients were stages as?Ⅰ(33.3%), whereas the other patients were classified as stage ⅡA(16.7%), stage ⅢB(16.7%), stage ⅢC(16.7%) and stage Ⅳ(16.7%), respectively. After a median follow-up of 2(0.03-8) years only 1 patient is still alive.CONCLUSION The frequency of incidental colorectal cancer in patients, who undergo surgery for stenotic CD, is low but associated with poor prognosis. However, surgeons need to be aware about the possibility of malignancy in stricturing CD, especially if localized in the rectum.

Recurrent abscess after primary successful endo-sponge treatment of anastomotic leakage following rectal surgery

AIM:To assess long-term efficacy of initially successful endo-sponge assisted therapy.METHODS:Between 2006 and 2009,consecutive patients who had undergone primary successful endo-sponge treatment of anastomotic leakage following rectal cancer surgery were enrolled in the study.Patients were recruited from 6 surgical departments in Vienna.Clinical and oncologic outcomes were assessed through routine endoscopic and radiologic follow-up examination.RESULTS:Twenty patients(7 female,13 male)were included.The indications for endosponge treatment were anastomotic leakage(n=17)and insufficiency of a rectal stump after Hartmann's procedure(n=3).All patients were primarily operated for rectal cancer.The overall mortality rate was 25%.The median followup duration was 17 mo(range 1.5-29.8 mo).Five patients(25%)developed a recurrent abscess.Median time between last day of endosponge therapy and occurrence of recurrent abscess was 255 d(range 21-733 d).One of these patients was treated by computed tomography-guided drainage and in 3 patients Hartmann's procedure had to be performed.Two patients(10%)developed a local tumor recurrence and subsequently died.CONCLUSION:Despite successful primary outcome,patients who receive endo-sponge therapy should be closely monitored in the first 2 years,since recurrence might occur.

Traction-assisted endoscopic mucosal resection for polypectomy in the large intestine

AIM: To evaluate if traction-assisted endoscopic mucosal resection (TA-EMR) is feasible and if it enables en bloc resection of colorectal lesions. METHODS: Seven patients with a total of 12 colorectal adenomas were prospectively enrolled. All lesions were removed by TA-EMR: one hemostatic clip tied to a white silk suture was applied to the base of the lesion to allow traction through the working channel of the colonoscope. A conventional polypectomy snare was mounted over the suture and the lesion was pulled into the snare and resected in one piece. RESULTS: All 12 lesions (nine sessile) were resected en bloc with free lateral and vertical margins by using this novel technique, including five lesions (5/12, 41.6%) in less-accessible positions, where TA-EMR enabled complete visualization of the base before resection. Mean longest lesion and specimen sizes were 9 mm (range: 6-25 mm) and 11 mm in diameter (range: 7-17 mm),respectively. No serious procedure-related complications were observed. CONCLUSION: TA-EMR through the endoscope using a hemostatic clip and suture material is technically feasible. Visualization of colorectal lesions in less-accessible locations can be improved.

Is the type of insufflation a key issue in gastro-intestinal endoscopy?

Endoscopic procedures continue to play an emerging role in diagnosing and treating upper and lower gastrointestinal (GI) disorders. In particular, the introduction of colonoscopy in bowel cancer screening has underlined its promising role in decreasing the incidence of colorectal cancer and reducing tumour related mortality. To achieve these goals patients need to contemplate endoscopic examinations as painless and fearless procedures. The use of carbon dioxide (CO2) as an alternative insufflation gas in comparison to air has been considered as an essential key to improving patients’ acceptance in undergoing endoscopic procedures. CO2 is absorbed quickly through the bowel mucosa causing less luminal distension and potentially less abdominal pain. However, its exact role has not been defined completely. In particular, the beneficial use of CO2 in upper GI endoscopy and in sedated patients is still conflicting. In the present review, we aimed to assess the current evidence for using CO2 in endoscopy and to evaluate its potential role in the future.