Improved laparoscopic transanal pull-through technique for low-rectal cancer resection

Objective： We described the applicability and evaluated the advantages of improved laparoscopic transanal pull-through （ILTPT） for low-rectal cancer resection. Materials： ILTPT was performed in 4 patients. Five or 4 ports were used. After isolation and section of the inferior mesenteric vessels, the rectum and sigmoid colon was mobilized. Total mesorectal excision and dissection of the distal rectum from the puborectalis muscle was carried out under laparoscopic guidance. The sigmoid colon and rectum were exteriorized via the anus. The rectum was divided proximally. Next, a purse-string suture was placed in the proximal segment, and the distal end of the sigmoid colon was returned to the pelvic cavity. The distal rectum was divided with Curved cutter staplermade by Jonson-Jonson company. Dislodging specimen, the continuity of the intestinal tract was restored using PROXIMATE ILS Curved and Straight Intraluminal Staplers CDH29/33 （Ethicon） through the rectum. Results： None of the cases were converted to open surgery. Average operation time was 180 min （range, 160-210 min）. No blood loss or any other complications were noted. Average postoperative stay was 9 days. Complications such as necrosis, anastomotic leakage and stricture, and genitoudnary disorders were not found in any of the patients at the 1 m follow-up. Conclusion： This report suggests that ILTPT is feasible and safe in Anus-Conserving Operation for low Rectal Cancer without auxiliary incision. If only we hold the applicability of ILTPT less trauma, more beautiful.

Literature Review of the Frequency of Reoperations after One Stage Transanal Endorectal Pull-Through Procedure for Hirschsprung’s Disease in Children

Background: Transanal endorectal one-stage pull-through (TERPT) procedure in children with Hirschsprung’s disease (HD) has gained worldwide acceptance. However surgical success is often reported separately, while the necessity for true reoperation is difficult to establish. Aim: To evaluate the incidence of reoperations following TERPT procedure. The findings will be important in counseling and planning childcare for HD patients as well as providing a benchmark for single centers clinical results. Methods: A literature review of reported TERPT operations on children with HD between 1998 through 2011 was performed. Only planned TERPT operation reports were included. Information was collected with particular emphasis on reoperations and their reasons. Results: Out of 26 published articles 23 were included, reporting on 836 children, female/male ratio: 1/3.3, undergoing the TERPT procedure as the only operative intervention with described postoperative courses. The children comprised neonates, 3 years of age (12%). The average follow up was 18.5 (6 - 38) months. The resected bowel length mean was 20.5 cm. Forty-one reoperations were reported (4.9%), including 24 laparotomies, 8 laparoscopies, 6 colostomies and ileostomies in 3 children. Only 2 re-do TERPT were reported (0.2%). Seven patients were considered TERPT failures (0.8%) with 5 requiring diverting colostomies and additional transabdominal pull-through operations. Two myectomies were performed (0.2%). One child with aganglionosis underwent a Duhamel pull through. Two (0.2%) had serious damage to the urinary tract also one child with a vas deferens lesion was reoperated. Two bowel obstructions required adhesiolysis. Eight anastomotic dehiscences (0.9%) required surgery after reparation. One prolapse of the pulled through colon was reported. Six patients (0.7%) suffered anastomotic leaks. Anastomotic strictures rate was 2.8%, all repaired with anal dilatation. Conclusion: The review supports the low incidence of reported reoperations for the TERPT procedure.

A NEW MODIFICATION OF TRANSANAL SOAVE PULL-THROUGH PROCEDURE FOR HIRSCHSPRUNG’S DISEASE

Background One stage transanal Soave pull-through procedure （TSPP） is a recent popular operation in the treatment of Hirschsprung＇s disease （HD）. With no visible scar and a short hospital stay, it is well accepted by surgeons and mothers. In the conventional Soave procedure, a long rectal muscular cuff left for anocolic anastomosis might increase the incidence of postoperative enterocolitis and constipation. This study presents a modified transanal Soave pull-through procedure （MTSPP） which includes an oblique mucosectomy and an oblique anastomosis with a short split muscular cuff.. Methods A review of two groups of HD patients was made： 112 underwent conventional transanal Soave procedure from 1999 to 2001 （group 1） and 140 underwent modified transanal Soave procedure from 2002 to 2004 （group 2）. A comparison was made between the two groups on operative data and postoperative complications. The data included： age at the operation, operating time, blood loss, time to feeds and hospital stay, occurrence of postoperative enterocolitis or constipation, need for anal dilatation, postoperative bowel function and perianal skin problems. Results There was no significant difference between two groups with respect to age, gender, length of colon resected, operating time, blood loss and hospital stay. However occurrence of postoperative enterocolitis, constipation, anastomotic stricture and time needed for anal dilatation were evidently less in group 2 （MTSPP）. The mean operating time in group 1 was （106 ± 39） minutes with a range of 60 to 170 minutes; in group 2 was （101 ± 36） minutes with a range of 66 to 190 minutes. The average length of the bowel resected in group 1 was （24 ± 7） cm, range 15 to 58 cm; in group 2 was （26 ± 8） cm, range 15 to 70 cm. Two patients, one in each group, required laparoscopic assistance because of long aganglionic colon. Another patient in group 2 required laparotomy because of total colonic aganglionosis. Postoperative complications in group 1 included： temporary perianal excoriation in 34 patients （26 were 〈3 months of age）, enterocolitis in 21, anastomotic stricture in 11, recurrent constipation in 12, cuff abscess in 1, anastomosis leak in 1, soiling in 3 and rectal prolapse in 1. In group 2 post operative complications included： transient perianal excoriation in 37 patients （30 were 〈3 months of age）, enterocolitis in 13, anastomotic stricture in 5, recurrent constipation in 6, anastomotic leak in 1, adhesive bowel obstruction in 1 and soiling in 4. Complete bowel continence was found in 97 children （86.6%） in group 1 and in 129 children （92.1%） in group 2 at one year followup after operation. Conclusions Modified transanal Soave pull-through procedure for HD with oblique mucosectomy and anastomosis and a short split muscular cuff is a safe and feasible operation with low incidence of postoperative complication. It is an encouraging improvement of the conventional transanal Soave pull-through procedure. MTSPP is a preferable choice in the surgery of HD.

单纯经肛门直肠及内括约肌切除术治疗先天性巨结肠的探讨(附101例报告)

目的 探讨单纯经肛门直肠黏膜及内括约肌切除术治疗新生儿及儿童先天性巨结肠的效果. 方法 本组101例,在齿状线水平将直肠黏膜与肛管皮肤交界处环形切开,切开略大于直肠1/2周径的前壁肌层至黏膜下层,沿黏膜下层向上分离;后壁沿直肠纵肌向上分离,前后壁共同分离直达腹膜反折水平进入腹腔,切除大部分内括约肌及直肠后壁肌鞘行巨结肠根治术. 结果 101例均手术顺利,手术时间45～190 min,平均90 min.术中出血＜10 ml,无术后尿潴留,无伤口感染、肛门回缩及肛门狭窄.术后肠炎发生率2.3%(2/86),污粪的发生率由术后2个月的27%(22/82)下降至术后6个月的4%(3/82).78例肛门直肠测压,手术后1、2、3、6个月肛管静息压力比手术前明显减低(P＜0.05). 结论 经肛门内括约肌及直肠后壁肌鞘切除治疗巨结肠安全易行,可有效预防术后并发症的发生,同样适合在基层医院推广应用.

Mechanical intestinal obstruction due to isolated diffuse venous malformations in the gastrointestinal tract: A case report and review of literature

BACKGROUND Isolated gastrointestinal venous malformations(GIVMs)are extremely rare congenital developmental abnormalities of the venous vasculature.Because of their asymptomatic nature,the diagnosis is often quite challenging.However,as symptomatic GIVMs have nonspecific clinical manifestations,misdiagnosis is very common.Here,we report a case of isolated diffuse GIVMs inducing mechanical intestinal obstruction.A literature review was also conducted to summarize clinical features,diagnostic points,treatment selections and differential diagnosis in order that doctors may have a comprehensive understanding of this disease.CASE SUMMARY A 50-year-old man presented with recurrent painless gastrointestinal bleeding for two months and failure to pass flatus and defecate with nausea and vomiting for ten days.Digital rectal examination found bright red blood and soft nodular masses 3 cm above the anal verge.Computed tomography showed that part of the descending colon and rectosigmoid colon was thickened with phleboliths in the intestinal wall.Colonoscopy exhibited bluish and reddish multinodular submucosal masses and flat submucosal serpentine vessels.Endoscopic ultrasonography showed anechoic cystic spaces within intestinal wall.The lesions were initially thought to be isolated VMs involving part of the descending colon and rectosigmoid colon.Laparoscopic subtotal proctocolectomy,pullthrough transection and coloanal anastomosis and ileostomy were performed.Histopathology revealed intact mucosa and dilated,thin-walled blood vessels in the submucosa,muscularis,and serosa involving the entire colorectum.The patient recovered with complete symptomatic relief during the 52-mo follow-up period.CONCLUSION The diagnosis of isolated GIVMs is challenging.The information presented here is significant for the diagnosis and management of symptoms.

Sphincter Saving Surgeries for Locally Advanced Low Rectal Cancer after Neoadjuvant Chemoradiation

Background: Rectal cancer accounts for the largest distribution within one anatomical region of the large bowel, with approximately one third of all CRC located within the rectum. The Golden standard treatment of primary rectal cancer is curative surgical resection;however, a fine balance remains between disease cure and restoration of gastrointestinal continuity. Combined modality has proven efficacy in many malignant tumors with advantage of organ preservation. Methods: Forty nine (49) patients with low rectal carcinoma were included in a prospective study, between Jan 2007 and Jan 2012. Preoperative chemoradiation was administrated to all patients and subjected to different techniques of sphincter saving surgery. Stage I and Stage IV disease at diagnosis were excluded from the study. Results: Forty nine patients were included in the study. 27 (55%) patients were male and 22 (45%) were female;the age ranges from 23 years to 70 years with the median age 46 years. The main presenting symptoms were bleeding per rectum and tenesmus, Stage II 18 patients (36.7%), stage III 31 patients (63.3%). Complete clinical and pathological response in 3 patients (6%), and complete clinical response with only microscopically residual carcinoma in 20 patients (41%), partial response in 18 patients (36.7%), and no significant response in 8 patients (16%) 7 from 8 were mucoid carcinoma. Low anterior resection (LAR) in 22 patients (44.9%), Hartman’s procedure in 4 patients (8.1%), Coloanal pull-through (COP) was done in 19 patients (38.9%) and perineal colostomy in 4 patients (8.1%). For patients with colo-anal pull-through technique complete dehiscent and retraction observed in 2 cases, Major leakage in one case, stenosis in 4 cases. Conclusion: There is tendency of colorectal cancers to affect younger groups. Most patients presented in advanced stage. Neadjuvant chemo radiation is an excellent tool in sphincter saving surgery. Coloanal pull-through technique is not a widely spread technique for low rectal cancer with good oncological safety and acceptable functional outcome.

腹腔镜经肛门结肠肛管吻合在低位直肠癌保肛手术中的应用

目的探讨腹腔镜下低位直肠癌根治术中经肛门结肠肛管吻合术（腹腔镜改良Parks手术）的临床应用。方法回顾性分析2009年3月至2012年4月期间65例采用腹腔镜改良Parks手术患者的临床资料，评估其术后并发症以及肛门控粪、排尿和性功能状况。结果全组患者随访6～38月，术后出现吻合VI瘘2例，吻合口狭窄3例，发生肝转移1例，无局部复发病例。术后6月、1年和2年对排粪情况满意者分别占61．5％（40／65）、84．2％（48／57）和88．9％（40／45）。术后1月排尿功能障碍发生率为10．8％（7／65）；男性患者术后1月勃起功能障碍发生率为19．4％（7／36），射精功能障碍发生率27．8％（10／36）。女性患者术后1月对性生活满意者占65．5％（19／29）。结论腹腔镜改良Parks手术可以提高低位直肠癌患者的的保肛率和较满意的控粪、排尿及性功能。