BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and be...BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and better quality of life.In 2007,Whiteford et al reported the first natural orifice trans-anal endoscopic surgery(NOTES)sigmoidectomy using transanal endoscopic microsurgery.To date,all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.AIM To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.METHODS Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection.After preoperative work-up and bowel preparation,general anesthesia combined with endotracheal intubation was achieved.One dual-channel therapeutic endoscope was used.Carbon dioxide insufflation was performed during the operation.The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps:(1)The rectosigmoid colon was tattooed with India ink by submucosal injection;(2)Creation of gastrostomy by directed submucosal tunneling;(3)Peroral external traction using endoloop ligation;(4)Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling;(5)Peroral external traction-assisted dissection of the left side of the colon;(6)Transanal rectosigmoid specimen transection,where an anvil was inserted into the proximal segment after purse-string suturing;(7)Intracorporeal colorectal end-toend anastomosis using a circular stapler by a single stapling technique;and(8)Closure of gastrostomy using endoscopic clips.All animals were euthanized immediately after the procedure,abdominal exploration was performed,and the air-under-water leak test was carried out.RESULTS The procedure was completed in all three animals,with the operation time ranging from 193 min to 259 min.Neither major intraoperative complications nor hemodynamic instability occurred during the operation.The length of the resected specimen ranged from 7 cm to 13 cm.With the assistance of a transumbilical rigid grasper,intracorporeal colorectal,tension-free,end-to-end anastomosis was achieved in the three animals.CONCLUSION Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.展开更多
BACKGROUND Trans-anal endoscopic microsurgery(TEM)enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer.The rectum and retro-rect...BACKGROUND Trans-anal endoscopic microsurgery(TEM)enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer.The rectum and retro-rectal space might be the origin of uncommon neoplasms,benign and aggressive,certain require radical trans-abdominal surgery,while others can be treated by a less aggressive approach.In this study we report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.METHODS Between January 2008 to December 2019 a retrospective analysis was completed for all patients who underwent TEM for non-adenomatous rectal lesion or retro-rectal mass in our institution.Patients were discharged once diet was well tolerated and no complications were identified.They were evaluated at 3 wk post operatively,then at 3-mo intervals for the first 2 years and every 6 mo depending on the nature of the final pathology.Clinical examination and rectoscopy were performed during each of the follow-up visits.RESULTS Out of 198 patients who underwent TEM during the study period,18 had non-adenomatous rectal or retro-rectal lesions.Mean age was 47 years.The mean size of the lesions was 2.9 mm,with a mean distance from the anal margin of 7.9 cm.Mean surgical time was 97.8 min.There were no intra-operative neither late post-operative complications.Mean length of stay was 2.5 d.Mean patient follow-up duration was 42 mo.CONCLUSION TEM allows for reduced morbidity given its minimally invasive nature.Surgeons should be familiar with the technique but careful patient selection should be considered.It can be used safely for uncommon rectal and selected retro-rectal lesions without compromising outcomes.We believe that it should be reasonably considered as one of the surgical methods when treating rare lesions.展开更多
BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensi...BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions.CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery,a disposable platform designed to aid in transanal minimally invasive surgery.Traction of the polyp by forceps during the operation was dynamic,and applied at various points and in various directions.The polyp was removed en-bloc without complications in 1 h and 55 min.A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence.CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.展开更多
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 anorect...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.展开更多
Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse.Even more rarely,it becomes strangulated,necessitating emergency surgery.We describe an extremely rare case of in...Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse.Even more rarely,it becomes strangulated,necessitating emergency surgery.We describe an extremely rare case of incarcerated acute rectal prolapse,without a relevant previous history or symptoms of predisposing pathology.The patient underwent emergency perineal proctosigmoidectomy,the Altemeier operation,combined with diverting loop sigmoid colostomy.The postoperative course was quite uneventful with an excellent final result after colostomy closure.The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual case scenario of bowel incarceration.展开更多
Strangled rectal prolapse, the rare disease, is a proctological emergency. Its management is controversial. When it is not reducible and signs of ischemia are present, the Altemeierperineal rectosigmoidectomy remains ...Strangled rectal prolapse, the rare disease, is a proctological emergency. Its management is controversial. When it is not reducible and signs of ischemia are present, the Altemeierperineal rectosigmoidectomy remains the best treatment. This study aimed to report our experience on the management of strangled rectal prolapse about 1 case in a 45-year-old man, a holder of a rectal prolapse for 2 years. On admission, he had strangled prolapse for 24 hours with edema. After a vain attempt of manual reduction and installation of necrosis after 48 hours, he had an Altemeier rectosigmo?dectomy. The postoperative course was uneventful and the patient was discharged on the 6th postoperative day. The results were very good, after one year follow-up.展开更多
BACKGROUND Rectal prolapse in young women is rare.Although laparoscopic ventral mesh rectopexy is the standard procedure because of its lower recurrence rate,postoperative infertility is a concern.Perineal rectosigmoi...BACKGROUND Rectal prolapse in young women is rare.Although laparoscopic ventral mesh rectopexy is the standard procedure because of its lower recurrence rate,postoperative infertility is a concern.Perineal rectosigmoidectomy(Altemeier procedure)is useful for these patients.However,the risk of anastomotic leakage should be considered.Recently,the usefulness of fluorescence imaging with indocyanine green(ICG)to prevent anastomotic leakage was reported.We report a case of an adolescent woman with complete rectal prolapse who underwent ICG fluorescence imaging-assisted Altemeier rectosigmoidectomy.CASE SUMMARY A 17-year-old woman who had a mental disorder was admitted to our hospital for treatment for water intoxication.The patient also suffered from rectal prolapse,approximately 3 mo before admission.She was referred to our surgical department because recurrent rectal prolapse could worsen her psychiatric disorder.Approximately 10 cm of complete rectal prolapse was observed.However,the mean maximum anal resting and constriction pressures were within normal limits on anorectal manometry.Because she had the desire to bear children in the future,she underwent Altemeier perineal rectosigmoidectomy to prevent surgery-related infertility.We performed ICG fluorescence imaging at the same time as surgery to reduce the risk of anastomotic leakage.Her postoperative course was uneventful,and the rectal prolapse was completely resolved.She continued to do well 18 mo after surgery,without recurrence of the rectal prolapse.CONCLUSION ICG fluorescence imaging-assisted Altemeier perineal rectosigmoidectomy is useful in preventing postoperative anastomotic leakage in young as well as elderly patients.展开更多
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecati...The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be re- served for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotonin- ergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effec- tive in the treatment of patients with chronic constipa- tion. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coil who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treat- ment in dys-synergic defecation. Many surgical proce- dures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.展开更多
Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoa...Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions.Most patients with early rectal cancer can be adequately managed by surgery alone.However,a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery.Neoadjuvant therapy involves a variety of options including radiotherapy,chemotherapy used alone or in combination.Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery.The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes,within an intact mesorectal package,in order to minimise local recurrence.It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties.Pre-operative staging including CT thorax,abdomen,pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential.Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy.While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure,which includes patients with nodal involvement,extramural venous invasion and threatened circumferential margin.The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.展开更多
BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surg...BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surgery can be created to obviate the need for emergency surgery, its effects on long-term outcomes and the most practical management strategies for right-sided malignant colonic obstruction remain unclear.AIM To determine the appropriate management approach for right-sided malignant colonic obstruction.METHODS Forty patients with right-sided malignant colonic obstruction who underwent curative resection from January 2007 to April 2017 were included in the study.We compared the perioperative and long-term outcomes of patients who received bridges to surgery established using decompression tubes and those created using self-expandable metallic stents(SEMS). The primary outcome was the overall survival duration(OS) and the secondary endpoints were the diseasefree survival(DFS) duration and the preoperative and postoperative morbidity rates. Analysis was performed on an intention-to-treat basis.RESULTS There were 21 patients in the decompression tube group and 19 in the SEMS group. There were no significant differences in the perioperative morbidity rates of the two groups. The OS rate was significantly higher in the decompression tube group than in the SEMS group(5-year OS rate; decompression tube 79.5%,SEMS 32%, P = 0.043). Multivariate analysis revealed that the bridge to surgery using a decompression tube was significantly associated with the OS(hazard ratio, 17.41; P = 0.004). The 3-year DFS rate was significantly higher in thedecompression tube group than in the SEMS group(68.9% vs 45.9%; log-rank test,P = 0.032). A propensity score–adjusted analysis also demonstrated that the prognosis was significantly better in the decompression tube group than in the SEMS group.CONCLUSION The bridge to surgery using trans-nasal and trans-anal decompression tubes for right-sided malignant colonic obstruction is safe and may improve long-term outcomes.展开更多
A postoperative complication after Altemeier operation, so far never reported,is described in a 42 years old mentally disabled patient with external full thickness rectal prolapse who usually had prolonged straining a...A postoperative complication after Altemeier operation, so far never reported,is described in a 42 years old mentally disabled patient with external full thickness rectal prolapse who usually had prolonged straining at defecation.After 6 d from perineal rectosigmoidectomy, the patient,was discharged free of complications.Four days later he was readmitted in emergency for stran-gulated perineal trans-anastomotic ileal hernia that occurred at home during efforts to defecate.The clinical feature required an emergency operation for repositioning the ileal loops into the abdomen,resection of the necrotic ileum,and end colostomy.The outcome of the second operation was free of complication and the patient was discharged on the 6th postoperative day.In conclusion,after Altemeier operation prolonged straining at defecation should be carefully展开更多
Patients with an incarcerated rectal prolapse usually present in the emergency department where manual reduction is first attempted. If reduction is unsuccessful, an emergency laparotomy and internal reduction is requ...Patients with an incarcerated rectal prolapse usually present in the emergency department where manual reduction is first attempted. If reduction is unsuccessful, an emergency laparotomy and internal reduction is required. Edema in the rectal and perineal tissues and impaired blood flow are the main factors for a high percentage of anastomotic leaks. The traditional single stage perineal rectosigmoidectomy is not a safe surgical procedure for treating incarcerated or strangulated rectal prolapses associated with severe edema. Herein we report a case of an incarcerated rectal prolapse treated with the Notaras procedure.展开更多
基金Supported by Young and Middleaged Mainstay Talent Training Program of Fujian Provincial Health System,China,No.2014-ZQN-ZD-6.
文摘BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and better quality of life.In 2007,Whiteford et al reported the first natural orifice trans-anal endoscopic surgery(NOTES)sigmoidectomy using transanal endoscopic microsurgery.To date,all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.AIM To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.METHODS Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection.After preoperative work-up and bowel preparation,general anesthesia combined with endotracheal intubation was achieved.One dual-channel therapeutic endoscope was used.Carbon dioxide insufflation was performed during the operation.The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps:(1)The rectosigmoid colon was tattooed with India ink by submucosal injection;(2)Creation of gastrostomy by directed submucosal tunneling;(3)Peroral external traction using endoloop ligation;(4)Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling;(5)Peroral external traction-assisted dissection of the left side of the colon;(6)Transanal rectosigmoid specimen transection,where an anvil was inserted into the proximal segment after purse-string suturing;(7)Intracorporeal colorectal end-toend anastomosis using a circular stapler by a single stapling technique;and(8)Closure of gastrostomy using endoscopic clips.All animals were euthanized immediately after the procedure,abdominal exploration was performed,and the air-under-water leak test was carried out.RESULTS The procedure was completed in all three animals,with the operation time ranging from 193 min to 259 min.Neither major intraoperative complications nor hemodynamic instability occurred during the operation.The length of the resected specimen ranged from 7 cm to 13 cm.With the assistance of a transumbilical rigid grasper,intracorporeal colorectal,tension-free,end-to-end anastomosis was achieved in the three animals.CONCLUSION Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.
文摘BACKGROUND Trans-anal endoscopic microsurgery(TEM)enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer.The rectum and retro-rectal space might be the origin of uncommon neoplasms,benign and aggressive,certain require radical trans-abdominal surgery,while others can be treated by a less aggressive approach.In this study we report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.METHODS Between January 2008 to December 2019 a retrospective analysis was completed for all patients who underwent TEM for non-adenomatous rectal lesion or retro-rectal mass in our institution.Patients were discharged once diet was well tolerated and no complications were identified.They were evaluated at 3 wk post operatively,then at 3-mo intervals for the first 2 years and every 6 mo depending on the nature of the final pathology.Clinical examination and rectoscopy were performed during each of the follow-up visits.RESULTS Out of 198 patients who underwent TEM during the study period,18 had non-adenomatous rectal or retro-rectal lesions.Mean age was 47 years.The mean size of the lesions was 2.9 mm,with a mean distance from the anal margin of 7.9 cm.Mean surgical time was 97.8 min.There were no intra-operative neither late post-operative complications.Mean length of stay was 2.5 d.Mean patient follow-up duration was 42 mo.CONCLUSION TEM allows for reduced morbidity given its minimally invasive nature.Surgeons should be familiar with the technique but careful patient selection should be considered.It can be used safely for uncommon rectal and selected retro-rectal lesions without compromising outcomes.We believe that it should be reasonably considered as one of the surgical methods when treating rare lesions.
文摘BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions.CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery,a disposable platform designed to aid in transanal minimally invasive surgery.Traction of the polyp by forceps during the operation was dynamic,and applied at various points and in various directions.The polyp was removed en-bloc without complications in 1 h and 55 min.A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence.CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.
文摘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.
文摘Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse.Even more rarely,it becomes strangulated,necessitating emergency surgery.We describe an extremely rare case of incarcerated acute rectal prolapse,without a relevant previous history or symptoms of predisposing pathology.The patient underwent emergency perineal proctosigmoidectomy,the Altemeier operation,combined with diverting loop sigmoid colostomy.The postoperative course was quite uneventful with an excellent final result after colostomy closure.The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual case scenario of bowel incarceration.
文摘Strangled rectal prolapse, the rare disease, is a proctological emergency. Its management is controversial. When it is not reducible and signs of ischemia are present, the Altemeierperineal rectosigmoidectomy remains the best treatment. This study aimed to report our experience on the management of strangled rectal prolapse about 1 case in a 45-year-old man, a holder of a rectal prolapse for 2 years. On admission, he had strangled prolapse for 24 hours with edema. After a vain attempt of manual reduction and installation of necrosis after 48 hours, he had an Altemeier rectosigmo?dectomy. The postoperative course was uneventful and the patient was discharged on the 6th postoperative day. The results were very good, after one year follow-up.
文摘BACKGROUND Rectal prolapse in young women is rare.Although laparoscopic ventral mesh rectopexy is the standard procedure because of its lower recurrence rate,postoperative infertility is a concern.Perineal rectosigmoidectomy(Altemeier procedure)is useful for these patients.However,the risk of anastomotic leakage should be considered.Recently,the usefulness of fluorescence imaging with indocyanine green(ICG)to prevent anastomotic leakage was reported.We report a case of an adolescent woman with complete rectal prolapse who underwent ICG fluorescence imaging-assisted Altemeier rectosigmoidectomy.CASE SUMMARY A 17-year-old woman who had a mental disorder was admitted to our hospital for treatment for water intoxication.The patient also suffered from rectal prolapse,approximately 3 mo before admission.She was referred to our surgical department because recurrent rectal prolapse could worsen her psychiatric disorder.Approximately 10 cm of complete rectal prolapse was observed.However,the mean maximum anal resting and constriction pressures were within normal limits on anorectal manometry.Because she had the desire to bear children in the future,she underwent Altemeier perineal rectosigmoidectomy to prevent surgery-related infertility.We performed ICG fluorescence imaging at the same time as surgery to reduce the risk of anastomotic leakage.Her postoperative course was uneventful,and the rectal prolapse was completely resolved.She continued to do well 18 mo after surgery,without recurrence of the rectal prolapse.CONCLUSION ICG fluorescence imaging-assisted Altemeier perineal rectosigmoidectomy is useful in preventing postoperative anastomotic leakage in young as well as elderly patients.
基金Supported by Associazione Italiana Gastroenterologi and Endoscopisti Digestivi Ospedalieri, Via N Colajanni, 4, 00191 Roma, ItalySocietà Italiana di Chirurgia Colo-Rettale, Via Medici, 23, 10143 Torino, Italy
文摘The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be re- served for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotonin- ergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effec- tive in the treatment of patients with chronic constipa- tion. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coil who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treat- ment in dys-synergic defecation. Many surgical proce- dures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
基金Supported by NBCRI,Symptomatic Breast Unit,University Hospital Galway
文摘Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions.Most patients with early rectal cancer can be adequately managed by surgery alone.However,a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery.Neoadjuvant therapy involves a variety of options including radiotherapy,chemotherapy used alone or in combination.Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery.The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes,within an intact mesorectal package,in order to minimise local recurrence.It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties.Pre-operative staging including CT thorax,abdomen,pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential.Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy.While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure,which includes patients with nodal involvement,extramural venous invasion and threatened circumferential margin.The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.
文摘BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surgery can be created to obviate the need for emergency surgery, its effects on long-term outcomes and the most practical management strategies for right-sided malignant colonic obstruction remain unclear.AIM To determine the appropriate management approach for right-sided malignant colonic obstruction.METHODS Forty patients with right-sided malignant colonic obstruction who underwent curative resection from January 2007 to April 2017 were included in the study.We compared the perioperative and long-term outcomes of patients who received bridges to surgery established using decompression tubes and those created using self-expandable metallic stents(SEMS). The primary outcome was the overall survival duration(OS) and the secondary endpoints were the diseasefree survival(DFS) duration and the preoperative and postoperative morbidity rates. Analysis was performed on an intention-to-treat basis.RESULTS There were 21 patients in the decompression tube group and 19 in the SEMS group. There were no significant differences in the perioperative morbidity rates of the two groups. The OS rate was significantly higher in the decompression tube group than in the SEMS group(5-year OS rate; decompression tube 79.5%,SEMS 32%, P = 0.043). Multivariate analysis revealed that the bridge to surgery using a decompression tube was significantly associated with the OS(hazard ratio, 17.41; P = 0.004). The 3-year DFS rate was significantly higher in thedecompression tube group than in the SEMS group(68.9% vs 45.9%; log-rank test,P = 0.032). A propensity score–adjusted analysis also demonstrated that the prognosis was significantly better in the decompression tube group than in the SEMS group.CONCLUSION The bridge to surgery using trans-nasal and trans-anal decompression tubes for right-sided malignant colonic obstruction is safe and may improve long-term outcomes.
文摘A postoperative complication after Altemeier operation, so far never reported,is described in a 42 years old mentally disabled patient with external full thickness rectal prolapse who usually had prolonged straining at defecation.After 6 d from perineal rectosigmoidectomy, the patient,was discharged free of complications.Four days later he was readmitted in emergency for stran-gulated perineal trans-anastomotic ileal hernia that occurred at home during efforts to defecate.The clinical feature required an emergency operation for repositioning the ileal loops into the abdomen,resection of the necrotic ileum,and end colostomy.The outcome of the second operation was free of complication and the patient was discharged on the 6th postoperative day.In conclusion,after Altemeier operation prolonged straining at defecation should be carefully
文摘Patients with an incarcerated rectal prolapse usually present in the emergency department where manual reduction is first attempted. If reduction is unsuccessful, an emergency laparotomy and internal reduction is required. Edema in the rectal and perineal tissues and impaired blood flow are the main factors for a high percentage of anastomotic leaks. The traditional single stage perineal rectosigmoidectomy is not a safe surgical procedure for treating incarcerated or strangulated rectal prolapses associated with severe edema. Herein we report a case of an incarcerated rectal prolapse treated with the Notaras procedure.
