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.

Transperineal core-needle biopsy of a rectal subepithelial lesion guided by endorectal ultrasound after contrast-enhanced ultrasound: A case report

BACKGROUND Rectal subepithelial lesions(SELs) are commonly seen in endoscopic examination, generally manifested as bumps with a smooth surface. Precise preoperative diagnoses for rectal SELs are difficult because abnormal tissues are not easily to be obtained by regular endoscopic forceps biopsy. Traditional guidance modalities of preoperative biopsy, including endoscopic ultrasound, computed tomography, and transabdominal ultrasound, are often unsatisfactory. An updated, safe, and effective biopsy guidance method is required. We herein report a new biopsy guidance modality—endorectal ultrasound(ERUS) combined with contrastenhanced ultrasound(CEUS).CASE SUMMARY A 32-year-old woman complained of a mass inside the rectovaginal space for 9 years, which became enlarged within 1 year. A rectal SEL detected by endoscopy was suspected to be a gastrointestinal stromal tumor or exophytic uterine fibroid. Pathological diagnosis was difficult because of unsuccessful transabdominal core needle biopsy with insufficient tissues, as well as vaginal hemorrhage. A second biopsy was suggested after multiple disciplinary treatment discussion, which referred to a transperineal core needle biopsy(CNB) guided by ERUS combined with CEUS. Adequate samples were procured and rectal gastrointestinal stromal tumor was proved to be the pathological diagnosis. Imatinib was recommended for first-line therapy by multiple disciplinary treatment discussion. After the tumor shrunk, resection of the rectal gastrointestinal stromal tumor was performed through the posterior vaginal wall. Adjuvant therapy was applied and no recurrence or metastasis has been found by the last follow-up on December 13, 2019.CONCLUSION Transperineal CNB guided by ERUS and CEUS is a safe and effective preoperative biopsy of rectal SELs yet with some limitations.

Endorectal Magnetic Resonance Imaging and Spectroscopy Are Useful for Selecting Candidates for Biopsy among Patients with Persistently Elevated Prostate Specific Antigen

Objective: To evaluate the efficacy of endorectal Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spetroscopic Imaging (MRSI) combined with total prostate-specific antigen (tPSA) and free prostate-specific antigen (fPSA) in selecting candidates for biopsy. Subjects and Methods: 246 patients with elevated tPSA (median: 7.81 ng/ml) underwent endorectal MRI and MRSI before Transrectal Ultrasound (TRUS) biopsy (10 peripheral + 2 central cores);patients with positive biopsies were treated with radical intention;those with negative biopsies were followed up and underwent MRSI before each additional biopsy if tPSA rose persistently. Mean follow-up: 27.6 months. We compared MRI, MRSI, tPSA, and fPSA with histopathology by sextant and determined the association between the Gleason score and MRI and MRSI. We determined the most accurate combination to detect prostate cancer (PCa) using receiver operating curves;we estimated the odds ratios (OR) and calculated sensitivity, specificity, and positive and negative predictive values. Results: No difference in tPSA was found between patients with and without PCa (p = 0.551). In the peripheral zone, the risk of PCa increased with MRSI grade;patients with high-grade MRSI had the greatest risk of PCa over time (OR = 328.6);the model including MRI, MRSI, tPSA, and fPSA was more accurate (Area under Curve: AUC = 95.7%) than MRI alone (AUC = 85.1%) or fPSA alone (AUC = 78.1%), but not than MRSI alone (94.5%). In the transitional zone, the model was less accurate (AUC = 84.4%). The association (p = 0.005) between MRSI and Gleason score was significant in both zones. Conclusions: MRSI is useful in patients with elevated tPSA. High-grade MRSI lesions call for repeated biopsies. Men with negative MRSI may forgo further biopsies because a significantly high Gleason lesion is very unlikely.

Restaging rectal cancer following neoadjuvant chemoradiotherapy

Correct tumour restaging is pivotal for identifying the most personalised surgical treatment for patients with locally advanced rectal cancer undergoing neoadjuvant therapy,and works to avoid both poor oncological outcome and overtreatment.Digital rectal examination,endoscopy,and pelvic magnetic resonance imaging are the recommended modalities for local tumour restaging,while chest and abdominal computed tomography are utilised for the assessment of distant disease.The optimal length of time between neoadjuvant treatment and restaging,in terms of both oncological safety and clinical effectiveness of treatment,remains unclear,especially for patients receiving prolonged total neoadjuvant therapy.The timely identification of patients who are radioresistant and at risk of disease progression remains challenging.

How useful is rectal endosonography in the staging of rectal cancer?

It is essential in treating rectal cancer to have adequate preoperative imaging,as accurate staging can influence the management strategy,type of resection,and candidacy for neoadjuvant therapy.In the last twenty years,endorectal ultrasound(ERUS) has become the primary method for locoregional staging of rectal cancer.ERUS is the most accurate modality for assessing local depth of invasion of rectal carcinoma into the rectal wall layers(T stage) .Lower accuracy for T2 tumors is commonly reported,which could lead to sonographic overstaging of T3 tumors following preoperative therapy.Unfortunately,ERUS is not as good for predicting nodal metastases as it is for tumor depth,which could be related to the unclear definition of nodal metastases.The use of multiple criteria might improve accuracy.Failure to evaluate nodal status could lead to inadequate surgical resection.ERUS can accurately distinguish early cancers from advanced ones,with a high detection rate of residual carcinoma in the rectal wall.ERUS is also useful for detection of local recurrence at the anastomosis site,which might require fine-needle aspiration of the tissue.Overstaging is more frequent than understaging,mostly due to inflammatory changes.Limitations of ERUS are operator and experiencedependency,limited tolerance of patients,and limited range of depth of the transducer.The ERUS technique requires a learning curve for orientation and identification of images and planes.With sufficient time and effort,quality and accuracy of the ERUS procedure could be improved.

Why do we have so much trouble treating anal fistula?

Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases.The problem with this single,yet effective,treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses,the patient will have varying degrees of fecal incontinence from minor to total.In an attempt to preserve continence,various procedures have been proposed to deal with the fistulas.These include: (1) simple drainage (Seton);(2) closure of fistula tract using fibrin sealant or anal fistula plug;(3) closure of primary opening using endorectal or dermal flaps,and more recently;and (4) ligation of intersphincteric fistula tract (LIFT).In most complex cases (i.e.Crohn’s disease),a proximal fecal diversion offers a measure of symptom-atic relief.The fact remains that an "ideal" procedure for anal fistula remains elusive.The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations.In essence,the price of preservation of continence at all cost is multiple and often different operations,prolonged disability and disappointment for the patient and the surgeon.Nevertheless,the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist.Conversely,an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.

Fecal incontinence - Challenges and solutions

Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient’s self-esteem and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.

Imaging in male-factor obstructive infertility

The main purpose of imaging evaluation in male infertility is to identify and treat correctable causes of infertility, such as obstruction of the seminal tract. Various imaging modalities are available to evaluate men with obstructive infertility including scrotal ultrasonography, transrectal ultrasound (TRUS), vasography, magnetic resonance imaging, seminal vesicle aspiration, seminal tract washout, and seminal vesiculography. To date the most reliable and accurate diagnostic technique for obstructive infertility is unclear. In this review article, we report the role of these modalities in diagnosis of obstructive infertility. Scrotal sonography is the initial modality, and if patient results indicate non obstructive azoospermia as varicocele or testicular pathology they will be treated according to standard protocols for management of these pathologies. If the patient findings indicate proximal obstructive azoospermia, they can be managed by vasoepididymostomy. If the scrotal ultrasound is normal, TRUS is the second imaging modality. Accordingly, they are classified into patients with criteria of obstructive infertility without urogenital cysts where TRUS-guided aspiration and seminal vesiculography can be performed and transurethral resection of the ejaculatory ducts (TURED) will be the management of choice. In patients with urogenital cyst, TRUS-guided cyst aspiration and opacification are performed. Ifthe cyst is communicating with the seminal tract, management will be transurethral incision of the cyst. If the cyst is not in communication, the obstruction may be relieved after cyst aspiration. If the obstruction is not relieved, TURED will be the management of choice. Sperm harvested during aspiration may be stored and used in assisted reproduction techniques. If the results of TRUS are inconclusive or doubtful, endorectal magnetic resonance imaging should be performed to serve as a "detailed map" for guiding corrective operative interventions.

Management of stage Ⅳ rectal cancer: Palliative options

Approximately 30% of patients with rectal cancer present with metastatic disease. Many of these patients have symptoms of bleeding or obstruction. Several treatment options are available to deal with the various complications that may afflict these patients. Endorectal stenting, laser ablation, and operative resection are a few of the options available to the patient with a malignant large bowel obstruction. A thorough understanding of treatment options will ensure the patient is offered the most effective therapy with the least amount of associated morbidity. In this review, we describe various options for palliation of symptoms in patients with metastatic rectal cancer. Additionally, we briefly discuss treatment for asymptomatic patients with metastatic disease.