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.

Development and Pull-through of Climate Science to Services in China

1. IntroductionThe impacts arising from climate change and climate variability pose major challenges to global and regional security and economic prosperity（UNFCCC,2015）.Some regions are more at risk than others, through heightened exposure to climatic hazards, and high vulnerability and exposure to such hazards. China, with its rapid economic development, large and growing population, and frequent occurrence of disasters associated with heavy rainfall, flooding, tropical cyclones,

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.

Literature Review of the Outcome 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) is frequently used worldwide. In order to give the families realistic expectations and to plan the medical care for the years after TERPT, the long term outcome is of great importance. Aim: To collect information on the long term outcome reported after one stage TERPT procedure for HD in children 0 - 15 years. Method: A literature review on the outcome of planned TERPT from 2005 through 2012 was carried out. Information was collected on the number of daily stools a few months postoperatively, incontinence and constipation and the measures taken to deal with these. Results: The reports are few and prospective studies were missing. The results show an initial high frequency of daily stools, 12% had later abnormal stool patterns, 21% had fecal incontinence and 10% had problems with constipation. Conclusion: In order to compare the long term outcome, it would be desirable to have uniform regular reports on the daily frequency of passed stools, incontinence and constipation during the first years after TERPT. Such knowledge would be of importance for the information given to the guardians of children with HD preoperatively to TERPT and in the planning of the future care. The findings can, furthermore, provide a benchmark for the outcome from a single centre.

Progressive Failure Analysis of Composite/Aluminum Riveted Joints Subjected to Pull-Through Loading

Out-of-plane mechanical properties of the riveted joints restrict the performance of the wing box assembly of airplane.It is necessary to investigate the pull-through performance of the composite/metal riveted joints in order to guide the riveting design and ensure the safety of the wing box assembly.The progressive failure mechanism of composite/aluminum riveted joint subjected to pull-through loading was investigated by experiments and finite element method.A progressive damage model based on the Hashin-type criteria and zero-thickness cohesive zone method was developed by VUMAT subroutine,which was validated by both open-hole tensile test and three-point bending test.Predicted load-displacement response,failure modes and damage propagation were analysed and compared with the results of the pull-through tests.There are 4 obvious characteristic stages on the load-displacement curve of the pull-through test and that of the finite element model:first load take-up stage,damage stage,second load take-up stage and failure stage.Relative error of stiffness,first load peak and second load peak between finite element method and experiments were 8.1%,-3.3%and 10.6%,respectively.It was found that the specimen was mainly broken by rivet-penetration fracture and delamination of plies of the composite laminate.And the material within the scope of the rivet head is more dangerous with more serious tensile damages than other regions,especially for 90°plies.This study proposes a numerical method for damage prediction and reveals the progressive failure mechanism of the hybrid material riveted joints subjected to the pull-through loading.

Clinical outcomes and ergonomics analysis of three laparoscopic techniques for Hirschsprung's disease

AIM: To report the clinical outcomes and ergonomics analysis of three laparoscopic approaches in the management of Hirschsprung's disease(HD).METHODS: There were 90 pediatric patients(63 boys, 27 girls; mean age: 3.6 ± 2.7 mo; range: 1.0-90.2 mo) who underwent laparoscopic endorectal pull-through Soave procedures for short- and long-segment HD in our hospital. Three laparoscopic approaches were used: conventional laparoscopic pull-through(CLP) in 30 patients between 2009 and 2013, single-incision laparoscopic pull-through(SILP) in 28 patients between 2010 and 2013, and hybrid single-incision laparoscopic pull-through(H-SILP) in 32 patients between 2011 and 2013. We applied the hybrid version of the single-incision approach in 2011 to preserve the cosmetic advantage of SILP and the ergonomic advantage of CLP. We retrospectively analyzed the clinical data, cosmetic results, and ergonomics of these three approaches to have a better understanding of the selection of one approach over another. RESULTS: The CLP, SILP, and H-SILP groups were similar in regard to age, sex, transition zone, blood loss, hospital stay, and intraoperative complications. Early and late postoperative results were not different, with equal daily defecation frequency and postoperative complications. No conversion to open technique was needed and none of the patients had recurrent constipation. With proper training, the ergonomics challenges were overcome and similar operative times were registered for the general operative time in the patients < 1 year of age and the short-segment HD patients. However, significantly shorter operative times were registered compared to SILP for patients > 1 year of age(CLP and H-SILP: 120 ± 15 min and 119 ± 12 min, respectively, vs 140 ± 7 min; P < 0.05) and for long-segment HD patients(152 ± 3.5 min and 154 ± 3.6 min, respectively, vs 176 ± 2.3 min; P < 0.05). The best cosmetic result was registered with the SILP(scarless), followed by the H-SILP(near scarless appearance) and the CLP(visible scars) procedures. CONCLUSION: Based on the results, we believed that the laparoscopic approach should be selected according to the age, transition zone, and desired cosmetic result.

Inferior pancreaticoduodenal artery aneurysm treated with coil packing and stent placement

Two cases with a pancreaticoduodenal arterial aneurysm accompanied with superior mesenteric artery(SMA) stenosis were previously described and both were treated surgically.However,for interventional treatment,securing a sufficient blood supply to the SMA should be a priority of treatment.We present the case of a 71-year-old male with a 20 mm diameter pancreaticoduodenal arterial aneurysm accompanied by SMA stenosis at its origin.The guidewire traverse from SMA to the aneurysm was difficult because of the tight SMA stenosis;however,the guidewire traverse from the celiac artery was finally successful and was followed by balloon angioplasty using a pull-through technique,leading to stent placement.Thereafter,coil packing through the SMA achieved eradication of the aneurysm without bowel ischemia.At the last follow-up computed tomography 8 mo later,no recurrence of the aneurysm was confirmed.The pull-through technique was useful for angioplasty for tight SMA stenosis in this case.

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.

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.

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.

A new modification of transanal Swenson pull-through procedure for Hirschsprung＇s disease

Background The one-stage pull-through procedures for Hirschsprung＇s disease （HD） have become popular because it is well accepted by surgeons and mothers with no visible scar and a short hospital stay. It represents the latest development in the concept of a minimally invasive surgery for HD. We introduce a new method of transanal one-stage pull-through for Hirschsprung＇s disease, different from the transanal Scare procedure. Methods One hundred and thirty-four patients aged 9 days to 5 years underwent a transanal one-stage pull-through procedure. The diagnosis was definite by barium enema or rectal biopsies preoperatively. The patients were anesthetized and placed in the lithotomy position. A urinary catheter was optional. Giving anorectal dilatations for half a minute, a pull-through of the rectum above the peritoneal reflection and into the intussusception was performed. Fine silk suturing was performed circumferentially at the level of that point which was used for traction for the distal end. Another circumferential suture was performed parallel 0.5 cm distance above the original one and used for traction for the proximal intestines. The full-thickness rectal wall was truncated between the above two circumferential sutures with cautery. The proximal intestines were pulled down and the mesenteric vessels were dissected with ligation until normal intestines were accessed; the presence of ganglion cells was determined by intraoperative rapid frozen section. The distal end was dissected anteriorly 2.5-3.5 cm above the dentate line. The posterior rectal wall was split longitudinally and dissected to a point 0.5-1.0 cm above the dentate line. The segment of the lesion was resected. The length of bowel resected ranged from 12 to 50 cm （median 16.5 cm）. An oblique anastomosis was made. Results The mean operating time was 70 minutes. Postoperative rectal dilation was not required. The patient tolerated feeding on the first postoperative day. Eighty-eight patients were followed-up. All these patients had 2-3 bowel movements per day at postoperative month 1. They were discharged within 4.5 days after the operation. Six patients presented with complications. All recovered by reoperation or conservative treatments. Conclusion The modification of the transanal Swenson pull-through procedure for Hirschsprung＇s Disease is an easy adaptation to a well-established technique and has a reasonable result.

Redo pull-through in total colonic aganglionosis due to residual aganglionosis:a single center’s experience

Background Reoperation for total colonic aganglionosis(TCA)may be required for residual aganglionosis after an initial radical operation.We aimed to investigate the symptoms,management,and outcomes of patients who required a redo pullthrough(Redo PT).Methods Nine TCA patients underwent Redo PT at our center between 2007 and 2017.Their medical records were reviewed.Parental telephone interviews that included disease-specific clinical outcomes were conducted,and post-operative complications and long-termoutcomes(including height-for-age/weight-for-age and bowel-function score)were compared to those of single-pull-through(Single PT)patients(n=21).Results All the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment.All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation,indicating residual aganglionosis.The median ages at the initial operation and Redo PT were 200 and 509 days,respectively.Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients.Postoperative complications included perianal excoriation(n=3),intestinal obstruction(n=2),enterocolitis(n=2),and rectovestibular fistula(n=1).Seven Redo PT patients were followed up for a mean time of 7.162.3 years;six(85.7%)had good growth and four(57.1%)had good bowel-function recovery.Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups(all P>0.05).Conclusion TCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation.Redo PT is effective and provides good long-termoutcomes comparable to those of patients who benefited from Single PT.