Low rectal cancer: abdominoperineal resection or low Hartmann resection? A postoperative outcome analysis.

BACKGROUND In distal rectum cancers, when the sphincters are not affected and it is not possible to perform a coloanal anastomosis because of the presence of comorbidities or the advanced age of the patient, a low Hartmann resection with total mesorectal excision can be performed. Low Hartmann resection is usually considered to be a shorter procedure and to have an inferior morbidity compared with abdominoperineal resection of the rectum. OBJECTIVE This study aimed to compare the postoperative outcome of a series of patients with low rectal cancer who have undergone either low Hartmann resection or abdominoperineal resection. DESIGN This study is a retrospective analysis of data collected i…

The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy

To evaluate the relationship between extent of internal sphincter division following open and closed sphincterotomy, as assessed by anal endosonography, with fissure persistence/recurrence and faecal incontinence.A total of 140 consecutive patients undergoing lateral internal sphincterotomy (LIS) for idiopathic chronic anal fissure were prospectively studied. Preoperative clinical assessment was performed together with a postoperative clinical and endosonographic examination. Three zones of the internal sphincter, identifiable by endosonography, were used to describe the uppermost extent of LIS. Primary end-points were fissure persistence/recurrence and faecal incontinence.A total of 140 pa…

Long-term evolution of continence and quality of life after sphincteroplasty for obstetric fecal incontinence

Purpose: This study was performed to evaluate the long-term evolution of continence and patient’s quality of life after surgical treatment for obstetric fecal incontinence.Methods: A prospective longitudinal study was conducted including consecutive patients who underwent sphincteroplasty for severe obstetric fecal incontinence. The first phase analyzed changes in continence and impact on quality of life. The second phase studied the long-term evolution reevaluating the same group of patients 6 years later. Degree of fecal incontinence was calculated using the Cleveland Clinic Score (CCS). Quality of life assessment was carried out with the Fecal Incontinence Quality of Life scale.Results: …

Prognostic Heterogeneity of Endosonographic T3 Rectal Cancer

PURPOSE: This study aimed to assess the prognostic implications of uT3 rectal carcinomas according to the tumor thickness and to analyze the correlation between this ultrasound-based parameter and other prognostic factors. METHODS: Seventy-four patients with uT3(pM0) rectal tumors underwent primary surgery from 1996 to 2003. Preoperative endorectal ultrasound was used to assess uN stage, maximum tumor perimeter, and maximum tumor thickness. An ultrasound maximum tumor thickness cutoff point for local recurrence subdividing T3 tumors into uT3a and uT3b was established. RESULTS: Median follow-up was 41 months (range, 24-59). The 5-year actuarial local and overall recurrence rates were 9.82 pe…

Reversal of Hartmann's procedure: a single-centre experience of 533 consecutive cases.

AIM Hartmann's procedure (HP) is common. However, restoration of intestinal continuity is not so frequent. The aim of this study was to determine predictive factors which might influence outcomes following the reversal of HP. METHOD All consecutive patients who underwent elective and emergency HP in a single institution between January 1999 and December 2014 were included. Data concerning patient, disease and treatment features were collected. Univariate and multivariate binary logistic regression models were used to determine prognostic factors. RESULTS A total of 533 consecutive patients underwent HP over the 16-year period. Factors that were associated with a higher probability of revers…

Prognostic implications of surgical specimen quality on the oncological outcomes of open and laparoscopic surgery in mid and low rectal cancer

Abstract Purpose Determine differences in pathologic outcomes between laparoscopic (LAP) and open surgery (OPEN) for mid and low rectal cancer and its influence in long-term oncological outcomes. Methods Retrospective case matched study at a tertiary institution. Adults with rectal cancer below 12 cm from the anal verge operated between January 2005 and September 2018 were included. Primary outcomes were quality of specimen, overall survival (OS), disease-free survival (DFS), and local recurrence (LR). Results The study included 311 patients, LAP = 108 (34.7%), OPEN = 203 (65,3%). A successful resection was accomplished in 81% of the LAP group and in 84.5% of the OPEN (p = 0.505). No differ…

Prospective evaluation of intraoperative peripheral nerve injury in colorectal surgery

Aim  Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery. Method  All patients who underwent major colorectal abdominal surgery in our Colorectal Unit between 1996 and 2009 were analyzed. Data on nerve injury were prospectively collected. Results  There were 2304 patients, of whom eight (0.3%) experienced intraoperative peripheral nerve injury. This occurred in 5/2211 (0.2%) open procedures and in 3/93 (3%) laparoscopic procedures. There wa…

Rectal advancement flaps for the treatment of transphincteric perianal fistulas: a three-dimensional endoanal ultrasound and quality of life assessment.

This study quantifies the damage to the internal anal sphincter (IAS) after a rectal mucosal advancement flap for a high transphincteric fistula in 16 patients using 3D-endoanal ultrasound. This was correlated with postoperative incontinence and quality of life scores. The median length of involved IAS preoperatively was 50 % (20-100) and 93.72 % for EAS (47.4-100 %). IAS division did not influence continence (p > 0.05). Continence deteriorated between the pre-, postoperative (p = 0.014) and six-month follow-up (p = 0.005), with no significant differences after one year (p > 0.05). The FIQOL score and SF-36 deteriorated initially, with recovery in all domains except for mental health after …

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

<i>Aim:</i> A prospective review of the complications of ileostomy construction and takedown. <i>Materials and Methods:</i> One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared. <i>Results:</i> One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterio…

Short-term outcomes of colorectal cancer surgery in older patients : a novel nomogram predicting postoperative morbi-mortality

Abstract Purpose To analyze short-term outcomes of curative-intent cancer surgery in all adult patients diagnosed with colorectal cancer undergoing surgery from January 2010 to December 2019 and determine risk factors for postoperative complications and mortality. Methods Retrospective study conducted at a single tertiary university institution. Patients were stratified by age into two groups: < 75 years and ≥ 75 years. Primary outcome was the influence of age on 30-day complications and mortality. Independent risk factors for postoperative adverse events or mortality were analyzed, and two novel nomograms were constructed. Results Of the 1486 patients included, 580 were older (≥ 75 year…

The occlusive tourniquet: a simple method for rectal stump washout during open and laparoscopic surgery.

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor…

Randomized clinical trial to evaluate the effects of perioperative supplemental oxygen administration on the colorectal anastomosis

Abstract Background Perioperative supplemental oxygen therapy may have beneficial effects on wound healing following colorectal surgery. The aim of this study was to evaluate the effects of such therapy on colorectal anastomotic pH and partial pressure of carbon dioxide (Pco2) gap. Methods Forty-five patients undergoing anterior resection for rectal or sigmoid cancer were randomized to receive 30 or 80 per cent perioperative oxygen. Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. Intragastric and anastomotic tonometric catheters were placed in each patient and intramucosal pH (pHi) was measured immediately after operation, and 6 and 24 h lat…

Review of the anatomic concepts in relation to the retrorectal space and endopelvic fascia: Waldeyer’s fascia and the rectosacral fascia

Objective  A precise anatomical study of the fascias within the retrorectal space is reported, analyzing and clarifying the anatomical concepts previously employed to describe Waldeyer’s and the rectosacral fascia. Method  The pelvis was dissected in 15 cadavers (10 males and five females). All specimens were divided in the median sagittal plane including the middle axis of the anal canal, to allow a correct visualization of and access to the retrorectal space. Results  The retrorectal space was limited anteriorly by the rectum and posterior mesorectum covered by a fine visceral fascia, and posteriorly by the sacrum covered by the parietal presacral fascia. The rectosacral fascia divided th…

Estomas de protección en cirugía colorrectal. ¿Cuándo y cómo realizarlos?

Resumen En los ultimos anos, el empleo de estomas de proteccion en cirugia colorrectal se ha incrementado, y tiene fundamentalmente tres grandes indicaciones: 1) traumatismos ano-recto-colicos graves; 2) enfermedad de Crohn con importante afectacion anorrectal y perineal, y 3) prevencion de complicaciones derivadas del fracaso anastomotico, fundamentalmente tras reseccion anterior baja por neoplasia de recto y tras proctocolectomia restauradora por colitis ulcerosa o poliposis colica familiar. En cuanto al tipo de estoma a realizar, en los casos de enfermedad o traumatismo anorrectal, lo habitual sera realizar una sigmoidostomia en asa, por lo que la derivacion se situa inmediatamente proxi…

Transvaginal rectocele repair reinforced with biological mesh - a video vignette.

Prognostic implications of circumferential location of distal rectal cancer

Aim  This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. Method  All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. Results  Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of …

Outcomes of Hartmann's procedure and subsequent intestinal restoration. Which patients are most likely to undergo reversal?

Abstract Background Aim of the study was to describe characteristics and outcomes of Hartmann's procedure (HP) and subsequent intestinal restoration. Methods Retrospective study including all patients who underwent HP over a period of 16 consecutive years. We propose a classification and regression tree for a more accurate view of the relationship between the variables related to intestinal restoration and their weighting in the decision to reverse HP. Results 533 patients were included. Overall morbidity rate of HP was 53.5% and mortality 21.0%. Overall morbidity of the intestinal continuity reconstruction was 47.3% and mortality 0.9%. Patients with a benign disease, aged under 69 years an…

Integrating Downstaging in the Risk Assessment of Patients With Locally Advanced Rectal Cancer Treated With Neoadjuvant Chemoradiotherapy: Validation of Valentini's Nomograms and the Neoadjuvant Rectal Score

Abstract Background Adjuvant chemotherapy is controversial in patients with locally advanced rectal cancer after preoperative chemoradiation. Valentini et al developed 3 nomograms (VN) to predict outcomes in these patients. The neoadjuvant rectal score (NAR) was developed after VN to predict survival. We aimed to validate these tools in a retrospective cohort at an academic institution. Patients and Methods VN and the NAR were applied to 158 consecutive patients with locally advanced rectal cancer treated with chemoradiation followed by surgery. According to the score, they were divided into low, intermediate, or high risk of relapse or death. For statistical analysis, we performed Kaplan-M…