Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China

AIM:To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy.METHODS:From January 2002 to March 2011,fourtyfive patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed.RESULTS:Patients with ulcerative colitis(n = 29) and familial adenomatous polyposis(n = 16) underwent ileal pouch-anal anastomosis with modified doublestapled mucosectomy.Twenty-eight patients underwent one-stage restorative proctocolectomy,ileal pouch anal anastomosis,protective ileostomy and the ileostomy was closed 4-12 mo postoperatively.Two-stage procedures were performed in seventeen urgent patients,proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy.Morbidity within the first 30 d of surgery occurred in 10(22.2%) patients,all of them could be treated conservatively.During the median follow-up of 65 mo,mild to moderate anastomotic narrowing was occurred in 4 patients,one patient developed persistent anastomotic stricture and need surgical intervention.Thirtyfive percent of patients developed at least 1 episode of pouchitis.There was no incontinence in our patients,the median functional Oresland score was 6,3 and 2 after 1 year,2.5 years and 5 years respectively.Nearly half patients(44.4%) reported "moderate functioning",37.7% reported "good functioning",whereas in 17.7% of patients "poor functioning" was observed after 1 year.Five years later,79.2% of patients with good function,16.7% with moderate function,only 4.2% of patients with poor function.CONCLUSION:The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising,with a low complication rate and good long-term functional results.

Can Mucosectomy be Always Performed in Complicated Cases of Choledochal Cysts

Introduction: If the surgical dissection is too risky in choledochal cyst, mucosectomy is defined as a beneficial technical method in the literature. To discuss in this manner, we present this case. Case: 9 years old girl was referred to our clinic due to multipl stones in the gallbladder. History and physicial examination could not be performed effectively because of her cerebral palsy. Ultrasonography showed choledochal cyst containing multipl stones. MR cholangiography showed multipl stones in the dilated choledochus. During the dissection, the cyst appeared extremely adherent to the adjacent structures and cyst wall was so thin and transparent. The mucosectomy was not thought to be a good option to carry out for this case. For this reason, cyst was totally excised. Discussion: The preferred method for choledochal cyst is total cyst excision and Roux-en Y hepaticoenterostomy. When the dissection is unsafe to perform, posterior wall mucosectomy may be performed. However, like in our case, when the diagnosis is delayed, the cyst wall may become too thin and may be attached very strongly to the adjacent structures. So, mucosectomy is impossible and full layer total cyst excision remains as the only alternative in spite of its high risks.

Endoscopic anti-reflux therapy for gastroesophageal reflux disease

Gastroesophageal reflux disease has an increasing incidence and prevalence worldwide.A significant proportion of patients have a suboptimal response to proton pump inhibitors or are unwilling to take lifelong medication due to concerns about long-term adverse effects.Endoscopic anti-reflux therapies offer a minimally invasive option for patients unwilling to undergo surgical treatment or take lifelong medication.The best candidates are those with a good response to proton pump inhibitors and without a significant sliding hiatal hernia.Transoral incisionless fundoplication and nonablative radiofrequency are the techniques with the largest body of evidence and that have been tested in several randomized clinical trials.Band-assisted ligation techniques,anti-reflux mucosectomy,antireflux mucosal ablation,and new plication devices have yielded promising results in recent noncontrolled studies.Nonetheless,the role of endoscopic procedures remains controversial due to limited long-term and comparative data,and no consensus exists in current clinical guidelines.This review provides an updated summary focused on the patient selection,technical details,clinical success,and safety of current and future endoscopic anti-reflux techniques.

Recent advancement of therapeutic endoscopy in the esophageal benign diseases

Over the past 30 years, the field of endoscopy has witnessed several advances. With the advent of endoscopic mucosal resection, removal of large mucosal lesions have become possible. Thereafter, endoscopic submucosal resection was refined, permitting en bloc removal of large superficial neoplasms. Such techniques have facilitated the development of antireflux mucosectomy, a promising novel treatment for gastroesophageal reflux. The introduction and use of over the scope clips has allowed for endoscopic closure of defects in the gastrointestinal tract, which were traditionally treated with surgical intervention. With the development of per-oral endoscopic myotomy(POEM), the treatment of achalasia and spastic disorders of the esophagus have been revolutionized. From the submucosal tunnelling technique developed for POEM, Per oral endoscopic tumor resection of subepithelial tumors was made possible. Simultaneously, advances in biotechnology have expanded esophageal stenting capabilities with the introduction of fully covered metal and plastic stents, as well as biodegradable stents. Once deemed a primarily diagnostic tool, endoscopy has quickly transcended to a minimally invasive intervention and therapeutic tool. These techniques are reviewed with regards to their application to benign disease of the esophagus.

Difficult colon polypectomy

Colorectal cancer (CRC) is one of the leading causes of death from cancer in the world. We now know that 90% of CRC develop from adenomatous polyps. Polypectomy of colon adenomas leads to a significant reduction in the incidence of CRC. At present most of the polyps are removed endoscopically. The vast majority of colorectal polyps identified at colonoscopy are small and do not pose a significant challenge for resection to an appropriately trained and skilled endoscopist. Advanced polypectomy techniques are intended for the removal of difficult colon polyps. We have defined a "difficult polyp" as any lesion that due to its size, shape or location represents a challenge for the colonoscopist to remove. Although many "difficult polyps" will be an easy target for the advanced endoscopist, polyps that are larger than 15 mm, have a large pedicle, are flat and extended, are difficult to see or are located in the cecum or any angulated portion of the colon should be always considered difficult. Although very successful,advanced resection techniques can potentially cause serious, even life-threatening complications. Moreover, post polypectomy complications are more common in the presence of difficult polyps. Therefore, any endos-copist attempting advanced polypectomy techniques should be adequately supervised by an expert or have an excellent training in interventional endoscopy. This review describes several useful tips and tricks to deal with difficult polyps.

Is patient satisfaction sufficient to validate endoscopic anti-reflux treatments?

Endoscopic anti-reflux treatment is emerging as a new option for gastroesophageal reflux disease(GERD)treatment in patients with the same indications as for laparoscopic fundoplication.There are many techniques,the first of which are transoral incisionless fundoplication(TIF)and nonablative radio-frequency(STRETTA)that have been tested with comparative studies and randomized controlled trials,whereas the other more recent ones still require a deeper evaluation.The purpose of the latter is to verify whether reflux is abolished or significantly reduced after intervention,whether there is a valid high pressure zone at the gastroesophageal junction,and whether esophagitis,when present,has disappeared.Unfortunately in a certain number of cases,and especially in the more recently introduced ones,the evaluation has been based almost exclusively on subjective criteria,such as improvement in the quality of life,remission of heartburn and regurgitation,and reduction or suspension of antacid and antisecretory drug consumption.However,with the most studied techniques such as TIF and STRETTA,an improvement in symptoms better than that of laparoscopic fundoplication can often be observed,whereas the number of acid episodes and acid exposure time are similar or higher,as if the acid refluxes are better tolerated by these patients.The suspicion of a local hyposensitivity taking place after antireflux endoscopic intervention seems confirmed by a Bernstein test at least for STRETTA.This examination should be done for all the other techniques,both old and new,to identify the ones that reassure rather than cure.In conclusion,the evaluation of the effectiveness of the endoscopic anti-reflux techniques should not be based exclusively on subjective criteria,but should also be confirmed by objective examinations,because there might be a gap between the improvement in symptoms declared by the patient and the underlying pathophysiologic alterations of GERD.