Modified stapled hemorrhoidopexy for lower postoperative stenosis: A five-year experience

BACKGROUND Stapled hemorrhoidopexy(SH)is currently a widely accepted method for treating the prolapse of internal hemorrhoids.Postoperative anal stenosis is a critical complication of SH.A remedy for this involves the removal of the circumferential staples of the anastomosis,followed by the creation of a hand-sewn anastomosis.Numerous studies have reported modified SH procedures to improve outcomes.We hypothesized that our modified SH technique may help reduce complications of anal stenosis after SH.AIM To compare outcomes of staple removal at the 3-and 9-o’clock positions during modified SH in patients with mixed hemorrhoids.METHODS This was a single-center,retrospective,observational study.Patients with grade III or IV hemorrhoids who underwent standard or modified SH at our colorectal center between January 1,2015,and January 1,2020,were included.The operation time,blood loss,length of hospital stay,and incidence of minor or major complic-ations were recorded.RESULTS Patients with grade III or IV hemorrhoids who underwent standard or modified SH at our colorectal center between January 1,2015 and January 1,2020,were included.Operation time,blood loss,length of hospital stay,and incidence of minor or major complications were recorded.We investigated 187 patients(mean age,50.9 years)who had undergone our modified SH and 313 patients(mean age,53.0 years)who had undergone standard SH.In the modified SH group,54%of patients had previously undergone surgical intervention for hemorrhoids,compared with the 40.3%of patients in the standard SH group.The modified SH group included five(2.7%)patients with anal stenosis,while 21(6.7%)patients in the standard SH group had complications of anal stenosis.There was a significant relationship between the rate of postoperative anal stenosis and the modified SH:0.251(0.085-0.741)and 0.211(0.069-0.641)in multiple regression analysis.The modified SH technique is a safe surgical method for advanced grade hemorrhoids and might result in a lower rate of postoperative anal stenosis than standard SH.CONCLUSION The modified SH technique is a safe surgical method for advanced grade hemorrhoids and might result in a lower rate of postoperative anal stenosis than standard SH.

Simulation and Experimental Study of Staple Line Reinforcement Surgery

The aim of this study was to evaluate the effectiveness of BM (basement membrane) and SIS (small intestine submucosa) composite extracellular matrix staple line reinforcement in surgical procedures through finite element modelling simulations and leak-proof performance experiments. The mechanical analyses of soft tissues with and without staple line reinforcement were performed by establishing finite element models of three tissues, namely, stomach, intestine and lungs, under the use scenarios of different anastomosis staple models;and the leak-proof performance of the staple line reinforcement was evaluated by simulating leak-proof experiments of gastric incision margins, intestinal sections, and lung incision margins in vitro. The results showed that the equivalent average stresses of the staple line reinforcement were increased by 20 kPa-68 kPa in gastric and intestinal tissues, and 8 kPa-22 kPa in lung tissues. and that the BM and SIS composite extracellular matrix staple line reinforcement could strengthen the anastomotic structure, and at the same time disperse the high stresses of the anastomosed tissues, which could effectively reduce the postoperative complications such as anastomotic bleeding and anastomotic leakage, and provide a safer and more effective optimized design for surgical mechanical anastomosis. It can effectively reduce postoperative complications such as anastomotic bleeding and anastomotic leakage, and provide a safer and more effective optimized design for surgical mechanical anastomosis.

Nutritional Value and Application of Broad Bean Nutrition Flour as a Combination of Staple Food

This paper introduced the definition and importance of combination of sta-ple food. With broad bean nutrition flour as a sample, the preparation of the combi-nation of staple food was also described. In addition, the main nutritional value of broad bean nutrition flour was introduced. Compared with those of other single flours, the nutritional value of broad bean nutrition flour was improved. Moreover, the nutrients in the broad bean nutrition flour would not be destroyed during the processing and preparation of staple food, and the processed steamed bread and raw noodle are more characteristic. The application value and prospects of broad bean nutrition flour, as a combination of staple food, were further discussed.

Staple半侧加压造成山羊胸椎不平衡发展的组织学观察

目的通过对Staple固定、加压生长期山羊胸椎的组织学观察,探讨加压侧对脊柱生长发育的影响。方法 9只未成年雌性山羊随机分为实验组(n=6)和对照组(n=3);实验组采用单侧多节段(T6-T11)跨椎间隙Staple固定;对照组只作相同切口暴露,不进行固定。4个月后获取T8、T9间隙(对照组相应节段)椎间盘及生长板,采用HE、Giemsa染色,镜下观察生长板及椎间盘情况。结果对照组未出现脊柱侧凸畸形,两侧生长板高度以及生长板肥大层细胞和终板软骨细胞形态无明显差异。实验组出现轻度脊柱侧凸畸形,术后4个月Cobb角为17.9°±5.6°;椎间隙上方生长板高度:加压侧(1.27±0.34)mm低于非加压侧的(2.05±0.19)mm,椎间隙下方生长板高度加压侧(0.77±0.31)mm也低于非加压侧的(2.1±0.29)mm;加压侧生长板肥大层细胞数量少、形态异常、排列不规则,非加压侧生长板肥大层细胞排列整齐,细胞形态饱满,胞质丰富,细胞核完整,与对照组无差别;终板软骨细胞也呈同样变化,加压侧与非加压侧软骨细胞数量明显减少,排列不紧密,细胞体积小,胞质较少,胞核扁平。结论半侧固定、加压抑制了固定侧脊柱生长板及终板软骨细胞的发育,可造成脊柱两侧不平衡发展。

Analysis on the Production Advantages of USA Pima Extra Long Staple Cotton

This paper defines the following advantages of ELS （Extra Long Staple） also known as Pima cotton planted in the United States： first, the only variety which is concentrated in the planting area with good soil moisture and fertilizer retention performances and abundant light and heat resources; second; advanced and practi- cal material equipment and technology; third; high yield and good quality, significant planting scale benefit; fourth, feasible and reliable modernized intensive farm man- agement mode with large-scale agricultural machinery operation; fifth, high-efficient social services and policy support system, as well as reasonable planting layout, good brand influence, synchronization of high yield and good quality with large-scale benefits. Although the production capability of Pima cotton in the United States is considered to be the largest and most powerful country in the world, compared with the ELS production in China, both have their own advantages and characteristics. Therefore, it is suggested that by using the ELS production experience ol the Unit- ed Stages for reference, China should make use of the modern breeding technJques to accelerate the modification of synthetic genetic features of ELS variety, try its best to breed the ELS variety which is suitable for mechanical plucking as soon as possible, actively develop new technology to simplify the whole cost saving cultiva- tion, reform ELS production organization, vigorously develop the social service sys- tem, and adjust and optimize the ELS industry support policies, so as to fundamen- tally improve the competitiveness of China＇s ELS in international market.

基于背景直方图的Staple目标跟踪算法

针对Staple算法在由于相机运动出现模糊情况下跟踪精度下降的问题,提出一种基于背景权重直方图的改进Staple目标跟踪算法。首先,针对传统颜色直方图忽略空间性的问题,提出对直方图引入位置权重;其次,利用背景区域颜色直方图抑制背景信息对目标区域直方图的影响,提出引入背景权重直方图,并完成直方图分类器的构建。该算法在OTB2015测试集上与其他5个先进算法进行实验比较,结果表明在距离精度和成功率上总体效果相对Staple分别提升了3.7%和2%。

Comparison of a modified anoscope and the purse-string anoscope in stapled haemorrhoidopexy

AIM： To compare the results of the anoscope of the PPH kit and a modified anoscope during stapled haemorrhoidopexy. METHODS： The hospital records of 37 patients who underwent stapled haemorrhoidopexy between 2001 and 2006 were reviewed. The purse-string suture anoscope in the PPH kit was used on 15 patients （Group 1）, and the modified anoscope was used on 22 patients （Group 2）. Demographic characteristics of the patients, operation time, surgeon＇s performance, analgesic requirement, and complications were compared. RESULTS： Operation time was significantly longer in Group 1 （42.0 4- 8.4 min vs 27.7 4- 8.0 min, P = 0.039）. The surgeons reported their operative performance as significantly better in Group 2 （the results of the assessments were poor in ten, medium in four and good in one in Group 1, while good in all patients in Group 2, P 〈 0.001）. The need for haemostatic sutures was significantly higher in Group 1 （six cases） and was needed in two cases in Group 2 （P = 0.034）. CONCLUSION： Operation time decreased and the surgeon＇s satisfaction increased with use of the modified anoscope, and fewer haemostatic sutures were required if the surgeon waited longer before and after firing the stapler.

联姻OA365跨国巨头Staples进军中国

位居世界500强的办公用品零售巨鳄,来自美国的Staples公司(NASDAQ代码:SPLS),在关注中国这个全球最具潜力的市场许久之后,终于来到了中国,这次与他们携手的是中国最大的网上办公用品销售企业--上海上信电子商务有限公司(OA365).

Progress of potato staple food research and industry development in China

Potato is the largest non-cereal food crop worldwide and ranked as the world＇s fourth most important food crop after rice, wheat, and maize. Potato is a vital food-security crop and substitute for cereal crop considering its high yield and great nutritive value. Therefore, by replacing wheat, rice or maize in traditional staple foods partly by potato, the nutritional value of traditional foods and the utilization of potato are expected to be improved. China is the largest potato producer worldwide in terms of either volume or area. However, majority of potatoes are consumed as fresh vegetables for cuisine, and the industrial processing rate is much lower than the global average. Thus, research and development for nutritional potato stable food suitable for the dietary habits of Chinese residents are of great significance. However, we still confronted plenty of constraints in the development of potato staple food. In order to develop potato staple food suitable for Chinese residents＇ dietary habit like noodles, Mantou（steamed bread）, rice and rice noodles, also to industrialize production of potato staple foods, some transformations need to be realized. Independent innovation is the only choice to realize the potato staple food processing and industrial development strategy on the technical level. Thus a lot of researches have been done to promote the development of potato staple food in China. Up to now, we already developed a series kinds of potato staple foods and some of these staple foods have already been widely promoted in Chinese markets.

Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer:A meta-analysis

AIM: To compare the outcomes of hand-sewn(HS) and linearly stapled(LS) esophagogastric anastomosis for esophageal cancer.METHODS: Before beginning this study, a rigorous protocol was established according to the recommendations of the Cochrane Collaboration. Databases and references were searched for all randomizedcontrolled trials and comparative clinical studies that compared LS with HS esophagogastric anastomosis for esophageal cancer. The primary outcomes compared were anastomotic leak and stricture. Subgroup analyses were performed according to site of anastomosis.RESULTS: Fifteen studies were used, comprising 3203 patients(n = 2027 LS and 1176 HS). Primary outcome analysis revealed a significant decrease in anastomotic leakage(RR = 0.51, 95%CI: 0.41-0.65; P < 0.00001) a s s o c i a t e d w i t h L S a n a s t o m o s i s. A s i g n i f i c a n t l y reduced rate of anastomotic stricture associated with LS was also found(RR = 0.56, 95%CI: 0.49-0.64; P < 0.00001). A subgroup analysis according to the site of anastomosis revealed a significantly reduced rate of anastomotic stricture(P < 0.00001). Although there was no significant difference in the decrease in thoracic anastomotic leakage, there was a significant decrease in cervical anastomotic leakage associated with LS(P < 0.00001).CONCLUSION: This meta-analysis indicates that the LS technique contributes to a reduced rate of leakage and stricture compared with the HS method.

Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception

AIM:To evaluate the safety and efficacy of stapled transanal rectal resection(STARR),and to analyze the outcome of the patients 12-mo after the operation.METHODS:From May 2007 to October 2008,50 female patients with rectocele and/or rectal intussusception underwent STARR.The preoperative status,perioperative and postoperative complications at baseline,3,6 and 12-mo were assessed.Data were collected prospectively from standardized questionnaires for the assessment of constipation[constipation scoring system,Longo’s obstructed defecation syndrome(ODS)score system,symptom severity score],patient satisfaction (visual analogue scale),and quality of life(Patient Assessment of Constipation-Quality of Life Questionnaire).RESULTS:At a 12-mo follow-up,significant improvement in the constipation scoring system,ODS score system,symptom severity score,visual analog scale and quality of life(P<0.0001)was observed.The symptoms of constipation improved in 90%of patients at 12 mo after surgery.The self-reported definitive outcome was excellent in 15(30%)patients,fairly good in 8(16%),good in 22(44%),and poor in 5(10%).CONCLUSION:STARR can be performed safely without major morbidity.Moreover,the procedure seems to be effective for patients with obstructed defecation associated with symptomatic rectocele and rectal intussusception.

Meta-analysis of stapled hemorrhoidopexy vs LigaSure hemorrhoidectomy

AIM: To compare outcome of stapled hemorrhoidopexy (SH) vs LigaSure hemorrhoidectomy (LH) by a meta-analysis of available randomized controlled trials (RCTs). METHODS: Databases, including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index updated to December 2012, were searched. The main outcomes measured were operating time, early postoperative pain, postoperative urinary retention and bleeding, wound problems, gas or fecal incontinence, anal stenosis, length of hospital stay, residual skin tags, prolapse, and recurrence. The meta-analysis was performed using the free software Review Manager. Differences observed between the two groups were expressed as the odds ratio (OR) with 95%CI. A fixedeffects model was used to pool data when statistical heterogeneity was not present. If statistical heterogeneity was present (P < 0.05), a random-effects model was used. RESULTS: The initial search identified 10 publica-tions. After screening, five RCTs published as full articles were included in this meta-analysis. Among the five studies, all described a comparison of the patient baseline characteristics and showed that there was no statistically significant difference between the two groups. Although most of the analyzed outcomes were similar between the two operative techniques, the operating time for SH was significantly longer than for LH (P < 0.00001; OR= -6.39, 95%CI: -7.68 -5.10). The incidence of residual skin tags and prolapse was significantly lower in the LH group than in the SH group [2/111 (1.8%) vs 16/105 (15.2%); P = 0.0004; OR= 0.17, 95%CI: 0.06-0.45). The incidence of recurrence after the procedures was significantly lower in the LH group than in the SH group [2/173 (1.2%) vs 13/174 (7.5%); P = 0.003; OR= 0.21, 95%CI: 0.07-0.59]. CONCLUSION: Both SH and LH are probably equally valuable techniques in modern hemorrhoid surgery. However, LigaSure might have slightly favorable immediate postoperative results and technical advantages.

Midterm outcome of stapled transanal rectal resection for obstructed defecation syndrome:A single-institution experience in China

AIM:To assess midterm results of stapled transanal rectal resection(STARR)for obstructed defecation syndrome(ODS)and predictive factors for outcome.METHODS:From May 2007 to May 2009,75 female patients underwent STARR and were included in the present study.Preoperative and postoperative workup consisted of standardized interview and physical examination including proctoscopy,colonoscopy,anorectal manometry,and defecography.Clinical and functional results were assessed by standardized questionnaires for the assessment of constipation constipation scoring system(CSS),Longo’s ODS score,and symptom severity score(SSS),incontinence Wexner incontinence score(WS),quality of life Patient Assessment of Constipation-Quality of Life Questionnaire(PAC-QOL),and patient satisfaction visual analog scale(VAS).Data were collected prospectively at baseline,12 and 30 mo.RESULTS:The median follow-up was 30 mo(range,30-46 mo).Late postoperative complications occurred in 11(14.7%)patients.Three of these patients required procedure-related reintervention(one diverticulectomy and two excision of staple granuloma).Although the recurrence rate was 10.7%,constipation scores(CSS,ODS score and SSS)significantly improved after STARR(P<0.0001).Significant reduction in ODS symptoms was matched by an improvement in the PAC-QOL and VAS(P<0.0001),and the satisfaction index was excellent in 25(33.3%)patients,good in 23(30.7%),fairly good in 14(18.7%),and poor in 13(17.3%).Nevertheless,the WS increased after STARR(P=0.0169).Incontinence was present or deteriorated in 8(10.7%)patients;6(8%)of whom were new onsets.Univariate analysis revealed that the occurrence of fecal incontinence(preoperative,postoperative or new-onset incontinence;P=0.028,0.000,and 0.007,respectively)was associated with the success of the operation.CONCLUSION:STARR is an acceptable procedure for the surgical correction of ODS.However,its impact on symptomatic recurrence and postoperative incontinence may be problematic.

Stapled gastro/duodenojejunostomy shortens reconstruction time during pylorus-preserving pancreaticoduodenectomy

AIM:To investigate whether a stapled technique is superior to the conventional hand-sewn technique for gastro/duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy(PpPD).METHODS:In October 2010,we introduced a mechanical anastomotic technique of gastro-or duodenojejunostomy using staplers during PpPD.We compared clinical outcomes between 19 patients who underwent PpPD with a stapled gastro/duodenojejunostomy(stapled anastomosis group)and 19 patients who underwent PpPD with a conventional hand-sewn duodenojejunostomy(hand-sewn anastomosis group).RESULTS:The time required for reconstruction was significantly shorter in the stapled anastomosis group than in the hand-sewn anastomosis group(186.0±29.4 min vs 219.7±50.0 min,P=0.02).In addition,intraoperative blood loss was significantly less(391.0±212.0 mL vs 647.1±482.1 mL,P=0.03)and the time to oral intake was significantly shorter(5.4±1.7d vs 11.3±7.9 d,P=0.002)in the stapled anastomosis group than in the hand-sewn anastomosis group.There were no differences in the incidences of delayed gastric emptying and other postoperative complications between the groups.CONCLUSION:These results suggest that stapled gastro/duodenojejunostomy shortens reconstruction time during PpPD without affecting the incidence of delayed gastric emptying.

Khubchandani's procedure combined with stapled posterior rectal wall resection for rectocele

BACKGROUND Obstructed defecation syndrome(ODS) is a widespread disease in the world.Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection(STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.AIM To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani's procedure with stapled posterior rectal wall resection.METHODS A cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients(group A) underwent Khubchandani's procedure with stapled posterior rectal wall resection and 51 patients(group B) underwent the STARR procedure.Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.RESULTS In group A, 42 patients underwent Khubchandani's procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min(group A) vs39.24 ± 6.53 min(group B). Mean hospital stay was 3.15 ± 0.70 d(group A) vs 3.14± 0.54 d(group B). Mean blood loss was 10.91 ± 2.52 mL(group A) vs 10.14 ± 1.86 m L(group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm(group A) vs 4.18 ± 0.95 cm(group B) preoperatively to 1.19 ± 0.43 cm(group A) vs 1.54 ± 0.82 cm(group B)one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients'(30/34, 88.2%) final outcomes were judged as effective and 4(4/34,11.8%) as moderate in group A, whereas in group B, 30(30/37, 81.1%) patients' outcomes were judged as effective, 5(5/37, 13.5%) as moderate, and 2(2/37,5.4%) as poor.CONCLUSION Khubchandani's procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Stapled transperineal repair for low-and mid-level rectovaginal fistulas:A 5-year experience and comparison with sutured repair

BACKGROUND Currently,rectovaginal fistula(RVF)continues to be a surgical challenge worldwide,with a relatively low healing rate.Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIM To evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODS This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University(Guangzhou,China).Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included.Among the 82 total patients,37 underwent repair with direct suturing and 45 underwent repair with stapling.Patient demographic data,Wexner faecal incontinence score,and operative data were analyzed.Recurrence rate and associated risk factors were assessed.RESULTS The direct suture and stapled repair groups showed similar clinical characteristics for aetiology,surgical history,fistula features,and perioperative Wexner score.The stapled repair group did not show superior results over the suture repair group in regard to operative time,blood loss,and hospital stay.However,the stapled repair group showed better postoperative Wexner score(1.04±1.89 vs 2.73±3.75,P=0.021),less intercourse pain(1/45 vs 17/37,P=0.045),and lower recurrence rate(6/45 vs 17/37,P=0.001).There was no protective effect from previous repair history,smaller diameter of fistula(<0.5 cm),better control of defecation(Wexner<10),or stapled repair.Direct suture repair and preoperative high Wexner score(>10)were risk factors for fistula recurrence.Furthermore,stapled repair gave better efficacy in treating complex RVFs(i.e.,multiple transperineal repair history,mid-level fistula position,and poor control of defecation).CONCLUSION Stapled transperineal repair is advantageous for management of RVF,providing a high primary healing rate and low recurrence rate.

Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders

AIM:To prospectively assess the eff icacy and safety of stapled trans-anal rectal resection(STARR) compared to standard conservative treatment,and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR.METHODS:Thirty patients(Female,28;age:51 ± 9 years) with rectocele or rectal intussusception,a defecation disorder,and functional constipation were submitted for STARR.Thirty comparable patients(Female,30;age 53 ± 13 years),who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol,were assessed.Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment.A responder was def ined as an absence of the Rome Ⅲ diagnostic criteria for functional constipation.Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients,respectively.RESULTS:After STARR,53% of patients were responders;during conservative treatment,75% were responders.After STARR,30% of the patients reported the use of laxatives,17% had intermittent anal pain,13% had anal leakage,13% required digital facilitation,6% experienced defecatory urgency,6% experienced fecal incontinence,and 6% required re-intervention.During macrogol therapy,23% of the patients complained of abdominal bloating and 13% of borborygmi,and 3% required digital facilitation.No preoperative symptom,defecographic,or manometric finding predicted the outcome of STARR.Post-operative defecography showed a statistically significant reduction(P < 0.05) of the rectal diameter and rectocele.The postoperative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified,and that rectal compliance was reduced(P = 0.01).CONCLUSION:STARR is not better and is less safe than macrogol in the treatment of defecation disorders.It could be considered as an alternative therapy in patients unresponsive to macrogol.

基于相关滤波的改进Staple人脸跟踪算法

在基于相关滤波的目标跟踪算法Staple的研究基础上,针对相关滤波在处理目标人脸消失、遮挡、脱离镜头时跟踪框漂移问题,本文提出一种自适应置信度机制的人脸跟踪算法.先通过人脸检测确定首帧人脸位置,再对相应位置的人脸的HOG特征与颜色特征进行提取,并预留两者特征,利用视频首帧提取的特征进行跟踪置信度判断,及时对融合特征进行更新.设计并实现了能够克服目标人脸位置移动、消失和表情姿态变化的人脸跟踪算法.实验表明,本文改进较前人算法有较大的提升.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis

BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.

Failed stapled rectal resection in a constipated patient with rectal aganglionosis

A rare case of a severely constipated patient with rectal aganglionosis is herein reported.The patient,who had no megacolon/megarectum,underwent a STARR,i.e.,stapled transanal rectal resection,for obstructed defecation,but her symptoms were not relieved.She started suffering from severe chronic proctalgia possibly due to peri-retained staples fibrosis.Intestinal transit times were normal and no megarectum/megacolon was found at barium enema.A diverting sigmoidostomy was then carried out,which was complicated by an early parastomal hernia,which affected stoma emptying.She also had a severe diverting proctitis,causing rectal bleeding,and still complained of both proctalgia and tenesmus.A deep rectal biopsy under anesthesia showed no ganglia in the rectum,whereas ganglia were present and normal in the sigmoid at the stoma site.As she refused a Duhamel procedure,an intersphincteric rectal resection and a refashioning of the stoma was scheduled.This case report shows that a complete assessment of the potential causes of constipation should be carried out prior to any surgical procedure.