Digital surgery is being increasingly used in phraseology and clinical application,driven by the advancing tide of technology.Its scope in treating patients with colorectal cancer is reviewed.A search was performed to...Digital surgery is being increasingly used in phraseology and clinical application,driven by the advancing tide of technology.Its scope in treating patients with colorectal cancer is reviewed.A search was performed to include a breadth of digital technologies,including virtual reality(VR),augmented reality(AR),artificial intelligence(AI),mobile health,and simulation.Many digital roles were identified in the 60 studies included.These were clinician-facing or patient-facing throughout the patient’s journey(screening,preoperative,intraoperative,postoperative)and involved the broader team(trainees,oncology,pathology).Colorectal cancer screening was improved via the use of digital technology,including virtual health assistants.Preoperative patient-facing VR enhances consent and reduces perioperative anxiety.For surgeons,enhanced awareness of vascular and visceral anatomy relative to the tumour helped with surgical planning,with the emerging concepts of‘virtual colectomy’and‘digital clone’.Pathologically,AI more accurately predicts lymph node metastasis following endoscopic polyp cancer excision,thus reducing over-treatment with surgery,and assesses the response to neoadjuvant treatment to guide selective surgery.Intraoperatively,AI facilitates real-time detection of anatomical landmarks,including autonomic nerves,ureters,and areolar tissue,to indicate the dissection plane.These intraoperative studies lacked a control group and outcome reporting(intraoperative,clinical,oncological,or functional),highlighting that this technology requires further development and study.There is a paucity of evidence regarding AR,such as intraoperative holographic overlay.Postoperative patient-facing digital technology can promote enhanced recovery,improve physical activity,and reduce sick-role maladaptation.For clinicians,AI can predict the short-term(complications)and long-term(survival)patient prognosis.VR could play an increasing role in training,with some evidence from validated virtual curricula.In summary,digital surgery has potential applications throughout the patient journey and along the virtuality continuum,showing advantages over conventional approaches in the preoperative and postoperative phases.Intraoperative,AI and AR methods have not yet been shown to have clinically significant advantages.As its scope grows,there are emerging implications for training,regulation,and ethics.展开更多
Colorectal cancer has a high incidence, and approxi-mately 60% of colorectal cancer patients are older than 70, with this incidence likely increasing in the near future. Elderly patients(> 70-75 years of age) are a...Colorectal cancer has a high incidence, and approxi-mately 60% of colorectal cancer patients are older than 70, with this incidence likely increasing in the near future. Elderly patients(> 70-75 years of age) are a very heterogeneous group, ranging from the very fit to the very frail. Traditionally, these patients have often been under-treated and recruited less frequently to clinical trials than younger patients, and thus are underrepresented in publications about cancer treatment. Recent studies suggest that fit elderly patients can be treated in the same way as their younger counterparts, but the treatment of frail patients with comorbidities is still a matter of controversy. Many factors should be taken into account, including fitness for treatment, the wishes of the patient and family, and quality of life. This review will focus on the existing evidence for surgical, oncologic, and palliative treatment in patients over 70 years old with colorectal cancer. Careful patient assessment is necessary in order to individualize treatment approach, and this should rely on a multidisciplinary process. More well-designed controlled trials are needed in this patient population.展开更多
AIM： To study the correlation between the patterns of subcellular expression of p16 and CDK4 in colorectal epithelia in the normal-adenoma-carcinoma sequence.METHODS： Paraffin sections of 43 cases of normal colorect...AIM： To study the correlation between the patterns of subcellular expression of p16 and CDK4 in colorectal epithelia in the normal-adenoma-carcinoma sequence.METHODS： Paraffin sections of 43 cases of normal colorectal epithelia and corresponding adenomas as well as carcinomas were analysed immunocytochemically for subcellular expression of p16 and CDK4 proteins.RESULTS： Most carcinomas showed more cytoplasmic overexpression for p16 and CDK4 than the adenomas from which they arised or the adjacent normal mucosa. Most normal or non-neoplastic epithelia showed more p16 and CDK4 expression in the nucleus than their adjacent adenomas and carcinomas. There was a significant difference between the subcellular expression pattern of p16 and CDK4 in normal-adenoma-carcinoma sequence epithelia （P 〈 0.001）. Neither p16 nor CDK4 subcellular patterns correlated with histological grade or Dukes＇ stage.CONCLUSION： Interaction of expression of p16 and CDK4 plays an important role in the Rb/p16 pathway.Overexpression of p16 and CDK4 in the cytoplasm, as well as loss expression of p16 in the nucleusmighlc be important in the evolution of colorectal carcinoma from adenoma and, of adenoma from normal epitheiia.展开更多
Cellular therapy may be the solution of challenging problems in colorectal surgery such as impaired healing leading to anastomotic leakage and metastatic colorectal cancer(CRC). This review aimed to illustrate the rol...Cellular therapy may be the solution of challenging problems in colorectal surgery such as impaired healing leading to anastomotic leakage and metastatic colorectal cancer(CRC). This review aimed to illustrate the role of cellular therapy in promotion of wound healing and management of metastatic CRC. An organized literature search for the role of cellular therapy in promotion of wound healing and management of metastatic CRC was conducted. Electronic databases including PubMed/Medline, Scopus, and Embase were queried for the search process. Two types of cellular therapy have been recognized, the mesenchymal stem cells(MSCs) and bone marrow-mononuclear cells(BM-MNCs) therapy.These cells have been shown to accelerate and promote healing of various tissue injuries in animal and human studies. In addition, experimental studies have reported that MSCs may help suppress the progression of colon cancer in rat models. This article reviews the possible mechanisms of action and clinical utility of MSCs and BM-MNCs in promotion of healing and suppression of tumor growth in light of the published literature. Cellular therapy has a potentially important role in colorectal surgery, particularly in the promotion of wound healing and management of metastatic CRC. Future directions of cellular therapy in colorectal surgery were explored which may help stimulate futures studies on the role of cellular therapy in colorectal surgery.展开更多
The dissemination of laparoscopic colorectal surgery(LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Pe...The dissemination of laparoscopic colorectal surgery(LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal andhuman tissue and synthetic materials. Studies have even demonstrated an improvement in trainees' laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.展开更多
Background: Androgen insensitivity syndrome(AIS), a disorder of sexual development in 46, XY individuals, is caused by loss-of-function mutations in the androgen receptor(AR) gene. A variety of tumors have been report...Background: Androgen insensitivity syndrome(AIS), a disorder of sexual development in 46, XY individuals, is caused by loss-of-function mutations in the androgen receptor(AR) gene. A variety of tumors have been reported in association with AIS, but no cases with colorectal cancer(CRC) have been described.Case presentation: Here, we present a male patient with AIS who developed multiple early-onset CRCs and his pedigree. His first cousin was diagnosed with AIS and harbored the same AR gene mutation, but with no signs of CRC. The difference in clinical management for the two patients was that testosterone treatment was given to the proband for a much longer time compared with the cousin. The CRC family history was negative, and no germline mutations in well-known CRC-related genes were identified. A single nucleotide polymorphism array revealed a microduplication on chromosome 22q11.22 that encompassed a micro RNA potentially related to CRC pathogenesis. In the proband, whole exome sequencing identified a polymorphism in an oncogene and 13 rare loss-of-function variants, of which two were in CRC-related genes and four were in genes associated with other human cancers.Conclusions: By pathway analysis, all inherited germline genetic events were connected in a unique network whose alteration in the proband, together with continuous testosterone stimulation, may have played a role in CRC pathogenesis.展开更多
As robotic surgery provides clinical benefits and increases on a global scale,it also signifies the transition from direct manual control of surgical instruments to digital connectivity and teleoperation.The digital c...As robotic surgery provides clinical benefits and increases on a global scale,it also signifies the transition from direct manual control of surgical instruments to digital connectivity and teleoperation.The digital coupling between human control inputs and surgical motion replaces the previous physical link.Robotic surgery is therefore in effect‘surgery-by-wire’,the term capturing the engineering phenomenon that has also occurred in the‘fly-by-wire’of aviation and‘drive-by-wire’of cars.This paper reviews the fundamental commonality across domains.Intrinsic to‘by-wire’control is digital processing,which generates the control signal to the effector.This processing enables a progressive spectrum of motion modulation,from precision and stability of motion,through assistance and envelope protection,to automation.Precision now manifests in all three domains.In modern aircraft and cars,higher-order assistance is commonplace,such as flight envelope protection,with analogous support in driving,as well as significant automation.In robotic surgery,such assistance and automation have not yet entered wider clinical practice,with concepts such as envelope protection requiring further definition.The digital interface combined with telecommunication has also enabled teleoperation in all domains.Therefore,motion‘by-wire’has enhanced performance across industries.A cross-domain perspective will be increasingly useful to facilitate technology transfer and catalyse progress in robotic surgery.As the pan-industry digital transformation evolves,important principles can be derived for application in robotic surgery.展开更多
The increasing use of robotic surgery has seen a wave of technology ripple through global healthcare.Similar changes occurred in aviation several decades ago.New robot types have increased access for both patients and...The increasing use of robotic surgery has seen a wave of technology ripple through global healthcare.Similar changes occurred in aviation several decades ago.New robot types have increased access for both patients and surgeons.The modern robotic curriculum therefore needs to train surgeons of varying experience,gaining access to several robot types,and based in centres around the world.Drawing on this analogy with aviation helps to derive principles for curriculum design,and considers humanemachine interface,non-technical skills,team training,and simulation.The components of the curriculum could be core(cross-platform),platform-specific,specialty-specific,and platform-transitional.Analogous concepts also emerge,including type rating,control as surgery-by-wire,spatio-haptic envelope,and virtual operations.The fourth industrial revolution sets anticipation for progress.展开更多
AIM: To study the results for the treatment of symptomatic hemorrhoids using rubber band ligation (RBL) method. METHODS: A retrospective study for 750 patients who came to the colorectal unit from June, 1998 to Septem...AIM: To study the results for the treatment of symptomatic hemorrhoids using rubber band ligation (RBL) method. METHODS: A retrospective study for 750 patients who came to the colorectal unit from June, 1998 to September, 2006, data was retrieved from archived fi les. RBL was performed using the Mc Gown applicator on an outpatient basis. The patients were asked to return to out-patient clinic for follow up at 2 wk, 1 mo, 6 mo and through telephone call every 6 mo for 2 years). RESULTS: After RBL, 696 patients (92.8%) were cured with no difference in outcome for second or third degree hemorrhoids (P = 0.31). Symptomatic recurrence was detected in 11.04% after 2 years. A total of 52 patients (6.93%) had 77 complications from RBL which required no hospitalization. Complications were pain, rectal bleeding and vaso-vagal symptoms(4.13%, 4.13% and 1.33% of patients, respectively). At 1 mo there were a significant improvement in mean SF-36 scores over baseline in five items, while after 2 years there were improvement in all items over baseline, but not significant. No significant manometeric changes after band ligation. CONCLUSION: RBL is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an out patient procedure with signifi cant improvement in quality of life. RBL doesn't alter ano-rectal functions.展开更多
AIM:To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.METHODS:MEDLINE, Pub Med, EMBASE, and other relevant data...AIM:To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.METHODS:MEDLINE, Pub Med, EMBASE, and other relevant database were searched to identify studies.Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.RESULTS:Twelve non-randomized case series studies with 574 patients were included in the review.No surgical mortality was described.Conversion was needed in 17 cases(2.9%), most often due to difficult adhesiolysis.Twenty eight patients(4.8%) presented with major complications.Seven(1.2%) mesh-related complications were reported.Most frequent complications were urinary tract infection and urinary retention.Mean recurrence rate was 4.7% with a median follow-up of 23 mo.Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%.Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages.Evaluation of functional score was disparate between studies.CONCLUSION:Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.展开更多
Locally recurrent rectal cancer(LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an...Locally recurrent rectal cancer(LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.展开更多
AIM:To study the results of stem-cell therapy under a Compassionate-use Program for patients with recurrent anal fistulae.METHODS:Under controlled circumstances,and approved by European and Spanish laws,a Compassionat...AIM:To study the results of stem-cell therapy under a Compassionate-use Program for patients with recurrent anal fistulae.METHODS:Under controlled circumstances,and approved by European and Spanish laws,a Compassionate-use Program allows the use of stem-cell therapy for patients with very complex anal fistulae.Candidates had previously undergone multiple surgical interventions that had failed to resolve the fistulae,and presented symptomatic recurrence.The intervention consisted of limited surgery(with closure of the internal opening),followed by local implant of stem cells in the fistula-tract wall.Autologous expanded adipose-derived stem cells were the main cell type selected for implant.The first evaluation was performed on the 8th postoperative week;outcome was classified as response or partial response.Evaluation one year after the intervention confirmed if complete healing of the fistula was achieved.RESULTS:Ten patients(8 male)with highly recurrent and complex fistulae were treated(mean age:49years,range:28-76 years).Seven cases were nonCrohn’s fistulae,and three were Crohn’s-associated fistulae.Previous surgical attempts ranged from 3to 12.Two patients presented with preoperative incontinence(Wexner scores of 12 and 13 points).After the intervention,six patients showed clinical response on the 8th postoperative week,with a complete cessation of suppuration from the fistula.Three patients presented a partial response,with an evident decrease in suppuration.A year later,six patients(60%)remained healed,with complete reepithelization of the external opening.Postoperative Wexner Scores were 0 in six cases.The two patients with previous incontinence improved their scores from12 to 8 points and from 13 to 5 points.No adverse reactions or complications related to stem-cell therapy were reported during the study period.CONCLUSION:Stem cells are safe and useful for treating anal fistulae.Healing can be achieved in severe cases,sparing fecal incontinence risk,and improving previous scoring.展开更多
AIM:To evaluate accuracy of three-dimensional endoanal ultrasound(3D-EAUS)as compared to 2D-EAUS and physical examination(PE)in diagnosis of perianal fistulas and correlate with intraoperative findings.METHODS:A prosp...AIM:To evaluate accuracy of three-dimensional endoanal ultrasound(3D-EAUS)as compared to 2D-EAUS and physical examination(PE)in diagnosis of perianal fistulas and correlate with intraoperative findings.METHODS:A prospective observational consecutive study was performed with patients included over a two years period.All patients were studied and operated on by the Colorectal Unit surgeons.The inclusion criteria were patients over 18,diagnosed with a criptoglandular perianal fistula.The PE,2D-EAUS and 3D-EAUS was performed preoperatively by the same colorectal surgeon at the outpatient clinic prior to surgery and the fistula anatomy was defined and they were classified in intersphincteric,high or low transsphincteric,suprasphincteric and extrasphincteric.Special attention was paid to the presence of a secondary tract,the location of the internal opening(IO)and the site of external opening.The results of these different examinations were compared to the intraoperative findings.Data regarding location of the IO,primary tract,secondary tract,and the presence of abscesses or cavities wasanalysed.RESULTS:Seventy patients with a mean age of 47years(range 21-77),51 male were included.Low transsphincteric fistulas were the most frequent type found(33,47.1%)followed by high transsphincteric(24,34.3%)and intersphincteric fistulas(13,18.6%).There are no significant differences between the number of IO diagnosed by the different techniques employed and surgery(P>0.05)and,there is a good concordance between intraoperative findings and the 2D-EAUS(k=0.67)and 3D-EAUS(k=0.75)for the diagnosis of the primary tract.The ROC curves for the diagnosis of transsphincteric fistulas show that both ultrasound techniques are adequate for the diagnosis of low transsphincteric fistulas,3D-EAUS is superior for the diagnosis of high transsphincteric fistulas and PE is weak for the diagnosis of both types.CONCLUSION:3D-EAUS shows a higher accuracy than 2D-EAUS for assessing height of primary tract in transsphincteric fistulas.Both techniques show a good concordance with intraoperative finding for diagnosis of primary tracts.展开更多
The ileal pouch anal anastomosis(IPAA)has revolutionised the surgical management of ulcerative colitis(UC)and familial adenomatous polyposis(FAP).Despite refinement in surgical technique(s)and patient selection,IPAA c...The ileal pouch anal anastomosis(IPAA)has revolutionised the surgical management of ulcerative colitis(UC)and familial adenomatous polyposis(FAP).Despite refinement in surgical technique(s)and patient selection,IPAA can be associated with significant morbidity.As the IPAA celebrated its 40th anniversary in 2018,this review provides a timely outline of its history,indications,and complications.IPAA has undergone significant modification since 1978.For both UC and FAP,IPAA surgery aims to definitively cure disease and prevent malignant degeneration,while providing adequate continence and avoiding a permanent stoma.The majority of patients experience long-term success,but“early”and“late”complications are recognised.Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction,but prompt intervention(either radiological or surgical)reduces the risk of pouch failure.Even in the absence of sepsis,pouch dysfunction is a longterm complication that may have a myriad of causes.Pouchitis is a common cause that remains incompletely understood and difficult to manage at times.10%of patients succumb to the diagnosis of pouch failure,which is traditionally associated with the need for pouch excision.This review provides a timely outline of the history,indications,and complications associated with IPAA.Patient selection remains key,and contraindications exist for this surgery.A structured management plan is vital to the successful management of complications following pouch surgery.展开更多
Anal fistula is a commonly encountered anal condition in the surgical practice.Despite being a benign condition,anal fistula remains to represent a surgical challenge,particularly the complex type of fistulas.One of t...Anal fistula is a commonly encountered anal condition in the surgical practice.Despite being a benign condition,anal fistula remains to represent a surgical challenge,particularly the complex type of fistulas.One of the common complications of anal fistula surgery is the persistence or recurrence of the pathology,both defined as failure of surgery.Recurrent anal fistulas after previous surgery represent an even more challenging problem since they are usually associated with a higher risk of re-recurrence and continence disturbance.The present review aimed to shed light on various aspects of recurrent anal fistulas,including the different definitions of failure after surgery,risk factors of recurrence,problems associated with management of recurrent fistulas,and assessment and treatment of recurrent anal fistulas.展开更多
AIM: To evaluate the efficacy and safety of botulinum toxin type A(BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases inclu...AIM: To evaluate the efficacy and safety of botulinum toxin type A(BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases including: Pub Med/MEDLINE, and Cochrane Central Register of Control ed Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and longterm clinical improvement, post-injection changes in electromyography(EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU(range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonographyguided technique, one study used EMG-guided technique,whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4%(range 37.5%-86.7%), this percentage declined to a median of 46%(range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between(37.5%-80%),(54%-86.7%), and(25%-86.6%), respectively. Fourteen(7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%. CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.展开更多
Endoscopic Imaging has progressed tremendously over the last few decades. Novel imaging technologies such as high-resolution and high-magnification white light endoscopy, narrow band imaging, optimal band imaging, aut...Endoscopic Imaging has progressed tremendously over the last few decades. Novel imaging technologies such as high-resolution and high-magnification white light endoscopy, narrow band imaging, optimal band imaging, auto? ourescence imaging and optical coherence tomography not only aid the endoscopist in detecting malignant or pre-malignant lesions but also assist in predicting histology. Recently, the introduction of Endocytoscopy (EC) and Confocal Endomicroscopy has taken us into a new realm of diagnostic endoscopy. With the ability to magnify up to 1000 ×, cellular structures can be visualized in real-time. This advance in technology could potentially lead to a paradigm shift negating the need to obtain biopsies. EC is, however, still in the early stages of development and further research needs to be carried out before it can be accepted as standard practice. This review will focus on the diagnostic utility of the Endocytoscope.展开更多
AIM:To compare the impact of carbon dioxide(CO2) and air insufflation on patient tolerance/safety in deeply sedated patients undergoing colonoscopy.METHODS:Patients referred for colonoscopy were randomized to receive ...AIM:To compare the impact of carbon dioxide(CO2) and air insufflation on patient tolerance/safety in deeply sedated patients undergoing colonoscopy.METHODS:Patients referred for colonoscopy were randomized to receive either CO2 or air insufflation during the procedure.Both the colonoscopist and patient were blinded to the type of gas used.During the procedure,insertion and withdrawal times,caecal intubationrates,total sedation given and capnography readings were recorded.The level of sedation and magnitude of patient discomfort during the procedure was assessed by a nurse using a visual analogue scale(VAS)(0-3).Patients then graded their level of discomfort and abdominal bloating using a similar VAS.Complications during and after the procedure were recorded.RESULTS:A total of 142 patients were randomized with 72 in the air arm and 70 in the CO2 arm.Mean age between the two study groups were similar.Insertion time to the caecum was quicker in the CO2 group at 7.3 min vs 9.9 min with air(P = 0.0083).The average withdrawal times were not significantly different between the two groups.Caecal intubation rates were 94.4% and 100% in the air and CO2 groups respectively(P = 0.012).The level of discomfort assessed by the nurse was 0.69(air) and 0.39(CO2)(P = 0.0155) and by the patient 0.82(air) and 0.46(CO2)(P = 0.0228).The level of abdominal bloating was 0.97(air) and 0.36(CO2)(P = 0.001).Capnography readings trended to be higher in the CO2 group at the commencement,caecal intubation,and conclusion of the procedure,even though this was not significantly different when compared to readings obtained during air insufflation.There were no complications in both arms.CONCLUSION:CO2 insufflation during colonoscopy is more efficacious than air,allowing quicker and better cecal intubation rates.Abdominal discomfort and bloating were significantly less with CO2 insufflation.展开更多
AIM To identify short-term and oncologic outcomes of pelvic exenterations(PE)for locally advanced primary rectal cancer(LAPRC)in patients included in a national prospective database.METHODS Few studies report on PE in...AIM To identify short-term and oncologic outcomes of pelvic exenterations(PE)for locally advanced primary rectal cancer(LAPRC)in patients included in a national prospective database.METHODS Few studies report on PE in patients with LAPRC.For this study,we included PE for LAPRC performed between 2006 and 2017,as available,from the Rectal Cancer Registry of the Spanish Association of Surgeons[Asociación Espa?ola de Cirujanos(AEC)].Primary endpoints included procedure-associated complications,5-year local recurrence(LR),disease-free survival(DFS)and overall survival(OS).A propensitymatched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint.RESULTS Eight-two patients were included.The mean age was 61.8±11.5 years.More than half of the patients experienced at least one complication.Surgical site infections were the most common complication(abdominal wound 18.3%,perineal closure 19.4%).Thirty-three multivisceral resections were performed,including two hepatectomies and four metastasectomies.The long-term outcomes of the 64 patients operated on before 2013 were assessed.The five-year LR was 15.6%,the distant recurrence rate was 21.9%,and OS was 67.2%,with a mean survival of 43.8 mo.R+ve resection increased LR[hazard ratio(HR)=5.58,95%CI:1.04-30.07,P=0.04].The quality of the mesorectum was associated with DFS.Perioperative complications were independent predictors of shorter survival(HR=3.53,95%CI:1.12-10.94,P=0.03).In the propensity-matched analysis,PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS.CONCLUSION PE is an extensive procedure,justified if disease-free margins can be obtained.Further studies should define indications,accreditation policy,and quality of life in LAPRC.展开更多
Purpose: Doppler-guided transanal haemorrhoidal dearterialisation (THD), with the addition of rectal mucopexy, has been gaining popularity as a minimally invasive haemorrhoidal treatment. The aim of this study was to ...Purpose: Doppler-guided transanal haemorrhoidal dearterialisation (THD), with the addition of rectal mucopexy, has been gaining popularity as a minimally invasive haemorrhoidal treatment. The aim of this study was to assess the outcomes of THD in patients with symptomatic haemorrhoids. Methods: All consecutive patients undergoing THD by a single surgeon over a 2 year period from 1st January 2010 were included. Results: THD was performed on 58 consecutive patients, with 46 (79.3%) having had previous haemorrhoidal treatment(s). Haemorrhoid grades were: 1 (n = 6);2 (n = 12);3 (n = 32);4 (n = 8). The median number of THD ligations was 7 (range 4 to 9) and rectal mucopexies 3 (range 1 to 3). All procedures (100%) were carried out as daycase, with 1 readmission within 30 days (anal fissure). No patients required return to theatre. After median follow-up of 10.5 weeks (range 1 to 48 weeks, 2 lost to follow-up), 53 (91%) patients reported symptomatic resolution or significant improvement. Two (3.4%) patients had post-operative complications (anal fissure). Two (3.4%) patients had further haemorrhoidal surgery following THD. Conclusions: THD is a safe daycase procedure for symptomatic haemorrhoids of all grades. It is an effective treatment in the short term, but longer-term follow-up is required to assess its symptomatic benefit more formally.展开更多
文摘Digital surgery is being increasingly used in phraseology and clinical application,driven by the advancing tide of technology.Its scope in treating patients with colorectal cancer is reviewed.A search was performed to include a breadth of digital technologies,including virtual reality(VR),augmented reality(AR),artificial intelligence(AI),mobile health,and simulation.Many digital roles were identified in the 60 studies included.These were clinician-facing or patient-facing throughout the patient’s journey(screening,preoperative,intraoperative,postoperative)and involved the broader team(trainees,oncology,pathology).Colorectal cancer screening was improved via the use of digital technology,including virtual health assistants.Preoperative patient-facing VR enhances consent and reduces perioperative anxiety.For surgeons,enhanced awareness of vascular and visceral anatomy relative to the tumour helped with surgical planning,with the emerging concepts of‘virtual colectomy’and‘digital clone’.Pathologically,AI more accurately predicts lymph node metastasis following endoscopic polyp cancer excision,thus reducing over-treatment with surgery,and assesses the response to neoadjuvant treatment to guide selective surgery.Intraoperatively,AI facilitates real-time detection of anatomical landmarks,including autonomic nerves,ureters,and areolar tissue,to indicate the dissection plane.These intraoperative studies lacked a control group and outcome reporting(intraoperative,clinical,oncological,or functional),highlighting that this technology requires further development and study.There is a paucity of evidence regarding AR,such as intraoperative holographic overlay.Postoperative patient-facing digital technology can promote enhanced recovery,improve physical activity,and reduce sick-role maladaptation.For clinicians,AI can predict the short-term(complications)and long-term(survival)patient prognosis.VR could play an increasing role in training,with some evidence from validated virtual curricula.In summary,digital surgery has potential applications throughout the patient journey and along the virtuality continuum,showing advantages over conventional approaches in the preoperative and postoperative phases.Intraoperative,AI and AR methods have not yet been shown to have clinically significant advantages.As its scope grows,there are emerging implications for training,regulation,and ethics.
文摘Colorectal cancer has a high incidence, and approxi-mately 60% of colorectal cancer patients are older than 70, with this incidence likely increasing in the near future. Elderly patients(> 70-75 years of age) are a very heterogeneous group, ranging from the very fit to the very frail. Traditionally, these patients have often been under-treated and recruited less frequently to clinical trials than younger patients, and thus are underrepresented in publications about cancer treatment. Recent studies suggest that fit elderly patients can be treated in the same way as their younger counterparts, but the treatment of frail patients with comorbidities is still a matter of controversy. Many factors should be taken into account, including fitness for treatment, the wishes of the patient and family, and quality of life. This review will focus on the existing evidence for surgical, oncologic, and palliative treatment in patients over 70 years old with colorectal cancer. Careful patient assessment is necessary in order to individualize treatment approach, and this should rely on a multidisciplinary process. More well-designed controlled trials are needed in this patient population.
文摘AIM： To study the correlation between the patterns of subcellular expression of p16 and CDK4 in colorectal epithelia in the normal-adenoma-carcinoma sequence.METHODS： Paraffin sections of 43 cases of normal colorectal epithelia and corresponding adenomas as well as carcinomas were analysed immunocytochemically for subcellular expression of p16 and CDK4 proteins.RESULTS： Most carcinomas showed more cytoplasmic overexpression for p16 and CDK4 than the adenomas from which they arised or the adjacent normal mucosa. Most normal or non-neoplastic epithelia showed more p16 and CDK4 expression in the nucleus than their adjacent adenomas and carcinomas. There was a significant difference between the subcellular expression pattern of p16 and CDK4 in normal-adenoma-carcinoma sequence epithelia （P 〈 0.001）. Neither p16 nor CDK4 subcellular patterns correlated with histological grade or Dukes＇ stage.CONCLUSION： Interaction of expression of p16 and CDK4 plays an important role in the Rb/p16 pathway.Overexpression of p16 and CDK4 in the cytoplasm, as well as loss expression of p16 in the nucleusmighlc be important in the evolution of colorectal carcinoma from adenoma and, of adenoma from normal epitheiia.
文摘Cellular therapy may be the solution of challenging problems in colorectal surgery such as impaired healing leading to anastomotic leakage and metastatic colorectal cancer(CRC). This review aimed to illustrate the role of cellular therapy in promotion of wound healing and management of metastatic CRC. An organized literature search for the role of cellular therapy in promotion of wound healing and management of metastatic CRC was conducted. Electronic databases including PubMed/Medline, Scopus, and Embase were queried for the search process. Two types of cellular therapy have been recognized, the mesenchymal stem cells(MSCs) and bone marrow-mononuclear cells(BM-MNCs) therapy.These cells have been shown to accelerate and promote healing of various tissue injuries in animal and human studies. In addition, experimental studies have reported that MSCs may help suppress the progression of colon cancer in rat models. This article reviews the possible mechanisms of action and clinical utility of MSCs and BM-MNCs in promotion of healing and suppression of tumor growth in light of the published literature. Cellular therapy has a potentially important role in colorectal surgery, particularly in the promotion of wound healing and management of metastatic CRC. Future directions of cellular therapy in colorectal surgery were explored which may help stimulate futures studies on the role of cellular therapy in colorectal surgery.
文摘The dissemination of laparoscopic colorectal surgery(LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal andhuman tissue and synthetic materials. Studies have even demonstrated an improvement in trainees' laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.
基金supported in part by funds obtained through an Italian law that allows taxpayers to allocate 0.5 percent share of their income tax contribution to a research institution of their choice
文摘Background: Androgen insensitivity syndrome(AIS), a disorder of sexual development in 46, XY individuals, is caused by loss-of-function mutations in the androgen receptor(AR) gene. A variety of tumors have been reported in association with AIS, but no cases with colorectal cancer(CRC) have been described.Case presentation: Here, we present a male patient with AIS who developed multiple early-onset CRCs and his pedigree. His first cousin was diagnosed with AIS and harbored the same AR gene mutation, but with no signs of CRC. The difference in clinical management for the two patients was that testosterone treatment was given to the proband for a much longer time compared with the cousin. The CRC family history was negative, and no germline mutations in well-known CRC-related genes were identified. A single nucleotide polymorphism array revealed a microduplication on chromosome 22q11.22 that encompassed a micro RNA potentially related to CRC pathogenesis. In the proband, whole exome sequencing identified a polymorphism in an oncogene and 13 rare loss-of-function variants, of which two were in CRC-related genes and four were in genes associated with other human cancers.Conclusions: By pathway analysis, all inherited germline genetic events were connected in a unique network whose alteration in the proband, together with continuous testosterone stimulation, may have played a role in CRC pathogenesis.
文摘As robotic surgery provides clinical benefits and increases on a global scale,it also signifies the transition from direct manual control of surgical instruments to digital connectivity and teleoperation.The digital coupling between human control inputs and surgical motion replaces the previous physical link.Robotic surgery is therefore in effect‘surgery-by-wire’,the term capturing the engineering phenomenon that has also occurred in the‘fly-by-wire’of aviation and‘drive-by-wire’of cars.This paper reviews the fundamental commonality across domains.Intrinsic to‘by-wire’control is digital processing,which generates the control signal to the effector.This processing enables a progressive spectrum of motion modulation,from precision and stability of motion,through assistance and envelope protection,to automation.Precision now manifests in all three domains.In modern aircraft and cars,higher-order assistance is commonplace,such as flight envelope protection,with analogous support in driving,as well as significant automation.In robotic surgery,such assistance and automation have not yet entered wider clinical practice,with concepts such as envelope protection requiring further definition.The digital interface combined with telecommunication has also enabled teleoperation in all domains.Therefore,motion‘by-wire’has enhanced performance across industries.A cross-domain perspective will be increasingly useful to facilitate technology transfer and catalyse progress in robotic surgery.As the pan-industry digital transformation evolves,important principles can be derived for application in robotic surgery.
文摘The increasing use of robotic surgery has seen a wave of technology ripple through global healthcare.Similar changes occurred in aviation several decades ago.New robot types have increased access for both patients and surgeons.The modern robotic curriculum therefore needs to train surgeons of varying experience,gaining access to several robot types,and based in centres around the world.Drawing on this analogy with aviation helps to derive principles for curriculum design,and considers humanemachine interface,non-technical skills,team training,and simulation.The components of the curriculum could be core(cross-platform),platform-specific,specialty-specific,and platform-transitional.Analogous concepts also emerge,including type rating,control as surgery-by-wire,spatio-haptic envelope,and virtual operations.The fourth industrial revolution sets anticipation for progress.
文摘AIM: To study the results for the treatment of symptomatic hemorrhoids using rubber band ligation (RBL) method. METHODS: A retrospective study for 750 patients who came to the colorectal unit from June, 1998 to September, 2006, data was retrieved from archived fi les. RBL was performed using the Mc Gown applicator on an outpatient basis. The patients were asked to return to out-patient clinic for follow up at 2 wk, 1 mo, 6 mo and through telephone call every 6 mo for 2 years). RESULTS: After RBL, 696 patients (92.8%) were cured with no difference in outcome for second or third degree hemorrhoids (P = 0.31). Symptomatic recurrence was detected in 11.04% after 2 years. A total of 52 patients (6.93%) had 77 complications from RBL which required no hospitalization. Complications were pain, rectal bleeding and vaso-vagal symptoms(4.13%, 4.13% and 1.33% of patients, respectively). At 1 mo there were a significant improvement in mean SF-36 scores over baseline in five items, while after 2 years there were improvement in all items over baseline, but not significant. No significant manometeric changes after band ligation. CONCLUSION: RBL is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an out patient procedure with signifi cant improvement in quality of life. RBL doesn't alter ano-rectal functions.
文摘AIM:To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.METHODS:MEDLINE, Pub Med, EMBASE, and other relevant database were searched to identify studies.Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.RESULTS:Twelve non-randomized case series studies with 574 patients were included in the review.No surgical mortality was described.Conversion was needed in 17 cases(2.9%), most often due to difficult adhesiolysis.Twenty eight patients(4.8%) presented with major complications.Seven(1.2%) mesh-related complications were reported.Most frequent complications were urinary tract infection and urinary retention.Mean recurrence rate was 4.7% with a median follow-up of 23 mo.Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%.Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages.Evaluation of functional score was disparate between studies.CONCLUSION:Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.
文摘Locally recurrent rectal cancer(LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.
文摘AIM:To study the results of stem-cell therapy under a Compassionate-use Program for patients with recurrent anal fistulae.METHODS:Under controlled circumstances,and approved by European and Spanish laws,a Compassionate-use Program allows the use of stem-cell therapy for patients with very complex anal fistulae.Candidates had previously undergone multiple surgical interventions that had failed to resolve the fistulae,and presented symptomatic recurrence.The intervention consisted of limited surgery(with closure of the internal opening),followed by local implant of stem cells in the fistula-tract wall.Autologous expanded adipose-derived stem cells were the main cell type selected for implant.The first evaluation was performed on the 8th postoperative week;outcome was classified as response or partial response.Evaluation one year after the intervention confirmed if complete healing of the fistula was achieved.RESULTS:Ten patients(8 male)with highly recurrent and complex fistulae were treated(mean age:49years,range:28-76 years).Seven cases were nonCrohn’s fistulae,and three were Crohn’s-associated fistulae.Previous surgical attempts ranged from 3to 12.Two patients presented with preoperative incontinence(Wexner scores of 12 and 13 points).After the intervention,six patients showed clinical response on the 8th postoperative week,with a complete cessation of suppuration from the fistula.Three patients presented a partial response,with an evident decrease in suppuration.A year later,six patients(60%)remained healed,with complete reepithelization of the external opening.Postoperative Wexner Scores were 0 in six cases.The two patients with previous incontinence improved their scores from12 to 8 points and from 13 to 5 points.No adverse reactions or complications related to stem-cell therapy were reported during the study period.CONCLUSION:Stem cells are safe and useful for treating anal fistulae.Healing can be achieved in severe cases,sparing fecal incontinence risk,and improving previous scoring.
文摘AIM:To evaluate accuracy of three-dimensional endoanal ultrasound(3D-EAUS)as compared to 2D-EAUS and physical examination(PE)in diagnosis of perianal fistulas and correlate with intraoperative findings.METHODS:A prospective observational consecutive study was performed with patients included over a two years period.All patients were studied and operated on by the Colorectal Unit surgeons.The inclusion criteria were patients over 18,diagnosed with a criptoglandular perianal fistula.The PE,2D-EAUS and 3D-EAUS was performed preoperatively by the same colorectal surgeon at the outpatient clinic prior to surgery and the fistula anatomy was defined and they were classified in intersphincteric,high or low transsphincteric,suprasphincteric and extrasphincteric.Special attention was paid to the presence of a secondary tract,the location of the internal opening(IO)and the site of external opening.The results of these different examinations were compared to the intraoperative findings.Data regarding location of the IO,primary tract,secondary tract,and the presence of abscesses or cavities wasanalysed.RESULTS:Seventy patients with a mean age of 47years(range 21-77),51 male were included.Low transsphincteric fistulas were the most frequent type found(33,47.1%)followed by high transsphincteric(24,34.3%)and intersphincteric fistulas(13,18.6%).There are no significant differences between the number of IO diagnosed by the different techniques employed and surgery(P>0.05)and,there is a good concordance between intraoperative findings and the 2D-EAUS(k=0.67)and 3D-EAUS(k=0.75)for the diagnosis of the primary tract.The ROC curves for the diagnosis of transsphincteric fistulas show that both ultrasound techniques are adequate for the diagnosis of low transsphincteric fistulas,3D-EAUS is superior for the diagnosis of high transsphincteric fistulas and PE is weak for the diagnosis of both types.CONCLUSION:3D-EAUS shows a higher accuracy than 2D-EAUS for assessing height of primary tract in transsphincteric fistulas.Both techniques show a good concordance with intraoperative finding for diagnosis of primary tracts.
基金the Mitchell J.Notaras Fellowship in Colorectal Surgery
文摘The ileal pouch anal anastomosis(IPAA)has revolutionised the surgical management of ulcerative colitis(UC)and familial adenomatous polyposis(FAP).Despite refinement in surgical technique(s)and patient selection,IPAA can be associated with significant morbidity.As the IPAA celebrated its 40th anniversary in 2018,this review provides a timely outline of its history,indications,and complications.IPAA has undergone significant modification since 1978.For both UC and FAP,IPAA surgery aims to definitively cure disease and prevent malignant degeneration,while providing adequate continence and avoiding a permanent stoma.The majority of patients experience long-term success,but“early”and“late”complications are recognised.Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction,but prompt intervention(either radiological or surgical)reduces the risk of pouch failure.Even in the absence of sepsis,pouch dysfunction is a longterm complication that may have a myriad of causes.Pouchitis is a common cause that remains incompletely understood and difficult to manage at times.10%of patients succumb to the diagnosis of pouch failure,which is traditionally associated with the need for pouch excision.This review provides a timely outline of the history,indications,and complications associated with IPAA.Patient selection remains key,and contraindications exist for this surgery.A structured management plan is vital to the successful management of complications following pouch surgery.
文摘Anal fistula is a commonly encountered anal condition in the surgical practice.Despite being a benign condition,anal fistula remains to represent a surgical challenge,particularly the complex type of fistulas.One of the common complications of anal fistula surgery is the persistence or recurrence of the pathology,both defined as failure of surgery.Recurrent anal fistulas after previous surgery represent an even more challenging problem since they are usually associated with a higher risk of re-recurrence and continence disturbance.The present review aimed to shed light on various aspects of recurrent anal fistulas,including the different definitions of failure after surgery,risk factors of recurrence,problems associated with management of recurrent fistulas,and assessment and treatment of recurrent anal fistulas.
文摘AIM: To evaluate the efficacy and safety of botulinum toxin type A(BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases including: Pub Med/MEDLINE, and Cochrane Central Register of Control ed Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and longterm clinical improvement, post-injection changes in electromyography(EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU(range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonographyguided technique, one study used EMG-guided technique,whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4%(range 37.5%-86.7%), this percentage declined to a median of 46%(range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between(37.5%-80%),(54%-86.7%), and(25%-86.6%), respectively. Fourteen(7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%. CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.
文摘Endoscopic Imaging has progressed tremendously over the last few decades. Novel imaging technologies such as high-resolution and high-magnification white light endoscopy, narrow band imaging, optimal band imaging, auto? ourescence imaging and optical coherence tomography not only aid the endoscopist in detecting malignant or pre-malignant lesions but also assist in predicting histology. Recently, the introduction of Endocytoscopy (EC) and Confocal Endomicroscopy has taken us into a new realm of diagnostic endoscopy. With the ability to magnify up to 1000 ×, cellular structures can be visualized in real-time. This advance in technology could potentially lead to a paradigm shift negating the need to obtain biopsies. EC is, however, still in the early stages of development and further research needs to be carried out before it can be accepted as standard practice. This review will focus on the diagnostic utility of the Endocytoscope.
文摘AIM:To compare the impact of carbon dioxide(CO2) and air insufflation on patient tolerance/safety in deeply sedated patients undergoing colonoscopy.METHODS:Patients referred for colonoscopy were randomized to receive either CO2 or air insufflation during the procedure.Both the colonoscopist and patient were blinded to the type of gas used.During the procedure,insertion and withdrawal times,caecal intubationrates,total sedation given and capnography readings were recorded.The level of sedation and magnitude of patient discomfort during the procedure was assessed by a nurse using a visual analogue scale(VAS)(0-3).Patients then graded their level of discomfort and abdominal bloating using a similar VAS.Complications during and after the procedure were recorded.RESULTS:A total of 142 patients were randomized with 72 in the air arm and 70 in the CO2 arm.Mean age between the two study groups were similar.Insertion time to the caecum was quicker in the CO2 group at 7.3 min vs 9.9 min with air(P = 0.0083).The average withdrawal times were not significantly different between the two groups.Caecal intubation rates were 94.4% and 100% in the air and CO2 groups respectively(P = 0.012).The level of discomfort assessed by the nurse was 0.69(air) and 0.39(CO2)(P = 0.0155) and by the patient 0.82(air) and 0.46(CO2)(P = 0.0228).The level of abdominal bloating was 0.97(air) and 0.36(CO2)(P = 0.001).Capnography readings trended to be higher in the CO2 group at the commencement,caecal intubation,and conclusion of the procedure,even though this was not significantly different when compared to readings obtained during air insufflation.There were no complications in both arms.CONCLUSION:CO2 insufflation during colonoscopy is more efficacious than air,allowing quicker and better cecal intubation rates.Abdominal discomfort and bloating were significantly less with CO2 insufflation.
文摘AIM To identify short-term and oncologic outcomes of pelvic exenterations(PE)for locally advanced primary rectal cancer(LAPRC)in patients included in a national prospective database.METHODS Few studies report on PE in patients with LAPRC.For this study,we included PE for LAPRC performed between 2006 and 2017,as available,from the Rectal Cancer Registry of the Spanish Association of Surgeons[Asociación Espa?ola de Cirujanos(AEC)].Primary endpoints included procedure-associated complications,5-year local recurrence(LR),disease-free survival(DFS)and overall survival(OS).A propensitymatched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint.RESULTS Eight-two patients were included.The mean age was 61.8±11.5 years.More than half of the patients experienced at least one complication.Surgical site infections were the most common complication(abdominal wound 18.3%,perineal closure 19.4%).Thirty-three multivisceral resections were performed,including two hepatectomies and four metastasectomies.The long-term outcomes of the 64 patients operated on before 2013 were assessed.The five-year LR was 15.6%,the distant recurrence rate was 21.9%,and OS was 67.2%,with a mean survival of 43.8 mo.R+ve resection increased LR[hazard ratio(HR)=5.58,95%CI:1.04-30.07,P=0.04].The quality of the mesorectum was associated with DFS.Perioperative complications were independent predictors of shorter survival(HR=3.53,95%CI:1.12-10.94,P=0.03).In the propensity-matched analysis,PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS.CONCLUSION PE is an extensive procedure,justified if disease-free margins can be obtained.Further studies should define indications,accreditation policy,and quality of life in LAPRC.
文摘Purpose: Doppler-guided transanal haemorrhoidal dearterialisation (THD), with the addition of rectal mucopexy, has been gaining popularity as a minimally invasive haemorrhoidal treatment. The aim of this study was to assess the outcomes of THD in patients with symptomatic haemorrhoids. Methods: All consecutive patients undergoing THD by a single surgeon over a 2 year period from 1st January 2010 were included. Results: THD was performed on 58 consecutive patients, with 46 (79.3%) having had previous haemorrhoidal treatment(s). Haemorrhoid grades were: 1 (n = 6);2 (n = 12);3 (n = 32);4 (n = 8). The median number of THD ligations was 7 (range 4 to 9) and rectal mucopexies 3 (range 1 to 3). All procedures (100%) were carried out as daycase, with 1 readmission within 30 days (anal fissure). No patients required return to theatre. After median follow-up of 10.5 weeks (range 1 to 48 weeks, 2 lost to follow-up), 53 (91%) patients reported symptomatic resolution or significant improvement. Two (3.4%) patients had post-operative complications (anal fissure). Two (3.4%) patients had further haemorrhoidal surgery following THD. Conclusions: THD is a safe daycase procedure for symptomatic haemorrhoids of all grades. It is an effective treatment in the short term, but longer-term follow-up is required to assess its symptomatic benefit more formally.
