TAMIS-flap technique: full-thickness advancement rectal flap for high perianal fistulae performed through transanal minimally invasive surgery

Introduction The formation of an advancement rectal flap could be technically demanding in the presence of high perianal of rectovaginal fistula, and the outcomes could be frustrated by inadequate view, bleeding and a poor exposure through the standard transanal approach. The application of the transanal minimally invasive surgery (TAMIS) to the advancement rectal flap procedure could overcome these difficulties. Technique In lithotomy position, a partial fistulectomy and a curette of the internal orifice were performed. The internal opening was closed on the anal sphincter plane. The dissection of the full thickness flap commenced through the classic transanal approach. The TAMIS port was inserted and the mobilization of the flap was continued proximally for as long as required. The laparoscopic visualization allowed a perfect view, a proper orientation of the flap and an accurate hemostasis. In order to avoid an excessive traction to the sutures, the length of the flap should be approximately twice as long as the distance of the internal orifice from the dentate line. Results Since November 2015, four patients with a recurrent high perianal fistula (median distance from the dentate line was 4.8 cm) underwent a TAMIS-flap procedure. The operation was performed at a median time from the diagnosis of 19 months. The median operative time was 115 minutes (range 90-150). No complications were recorded. Conclusions The TAMIS-flap procedure seems a promising technique to perform a safe dissection when a long advancement rectal flap is necessary to treat a high perianal or rectovaginal fistula. The use of laparoscopic instruments and the continuous pneumorectum allow to maintain an adequate visualization and to avoid complications that could negatively affect the outcomes of the procedure

Adaptive Immune Responses in Primary Cutaneous Sarcoidosis

Sarcoidosis is a multisystemic inflammatory disorder with cutaneous lesions present in about one-quarter of the patients. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of nonnecrotizing epithelial cell granulomas on histologic studies. The development and progression of specific cutaneous sarcoidosis involves a complex interaction between cells of the adaptive immune systems, notably T-lymphocytes and dendritic cells. In this paper, we will discuss the role of T-cells and skin dendritic cells in the development of primary cutaneous sarcoidosis and comment on the potential antigenic stimuli that may account for the development of the immunological response. We will further explore the contributions of selected cytokines to the immunopathological process. The knowledge of the adaptive immunological mechanisms operative in cutaneous sarcoidosis may subsequently be useful for identifying prevention and treatment strategies of systemic sarcoidosis

High complication rate in Crohn's disease surgery following percutaneous drainage of intra-abdominal abscess: a multicentre study

Intra-abdominal abscesses complicating Crohn's disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD

High complication rate in Crohn's disease surgery following percutaneous drainage of intra-abdominal abscess: a multicentre study

Introduction: Intra-abdominal abscesses complicating Crohn's disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD. Methods: This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing ileocolic resection for primary or recurrent CD from June 2018 to May 2019. The outcomes of patients who underwent radiological guided drainage prior to ileocolonic resection were compared to the patients who did not require preoperative drainage. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. Results: Amongst a group of 575 included patients who had an ileocolic resection for CD, there were 36 patients (6.2%) who underwent abscess drainage prior to surgery. Postoperative morbidity (44.4%) and anastomotic leak (11.1%) were significantly higher in the group of patients who underwent preoperative drainage. Conclusions: Patients with Crohn's disease who require preoperative radiological guided drainage of intra-abdominal abscesses are at increased risk of postoperative morbidity and septic complications following ileocaecal or re-do ileocolic resection

Influence of diabetes mellitus on inflammatory bowel disease course and treatment outcomes. A systematic review with meta-analysis

Diabetes Mellitus (DM) may occur in IBD and influence the disease progression

Atypical presentation and transabdominal treatment of chylothorax complicating esophagectomy for cancer

Chylotorax is a relatively uncommon and difficult to treat complication after esophagectomy for cancer. We report a case of a young adult male who underwent neoadjuvant chemoradiationtherapy followed by Ivor-Lewis esophagectomy for a squamous-cell carcinoma of the distal esophagus. During the postoperative course the patient presented recurrent episodes of hemodynamic instability mimicking cardiac tamponade, secondary to compression of the left pulmonary vein and the left atrium by a mediastinal chylocele. Mediastinal drainage and ligation of the cisterna chyli and the thoracic duct was successfully performed through a transhiatal approach

The impact of colectomy and restorative procedure on pouch function after ileo-pouch-anal anastomosis in ulcerative colitis. The icon fun study on behalf of the Italian Society of Colon and Rectal Surgery (SICCR) Inflammatory Bowel Diseases committee

background: available guidelines lack in indications on surgical standard in ulcerative colitis (UC) aims: to determine the role of surgical strategies of colectomy and proctectomy with pouch-anal-anastomosis (IPAA) on functional outcomes in a nationwide population multicenter study. the secondary aims consisted of perioperative outcomes and complications. methods: data on 379 patients who underwent total abdominal colectomy and proctectomy with ileo-pouch-anal-anastomosis (IPAA) with or without diverting ileostomy were retrospectively collected in a red cap multicenter-database searching for variables that could impact on pouch outcomes as cuffitis, pouchitis, anastomotic stenosis, pouch stenosis, failure or pathological low-anterior-resection-syndrome (LARS) score. results: mesocolic dissection sealing vessels at major trunks and from medial to lateral are associated with better outcomes. laparoscopy is associated with lower rate of cuffitis over time (p = 0.028). mesentery lengthening is associated with higher pouchitis rate (p = 0.015) and earlier failure (p < 0.0001). hand-sewn IPAA results in early anastomotic stenosis (p = 0.00011). the transanal-transection and single-stapling anastomosis (TTSS) showed to be protective against pouchitis. extended dissection of adhesions correlates with lower rate of pouchitis-episodes (p = 0.0057). conclusions: the study highlights advantages of laparoscopy. new techniques such as TTSS promise further improvements. mesentery lengthening correlates with high risk of pouch-failure and pouchitis, hand-sewn anastomosis increased risk of stenosis

Colorectal Cancer Outcomes of Robotic Surgery Using the HugoTM RAS System: The First Worldwide Comparative Study of Robotic Surgery and Laparoscopy

Background/Objectives: The aim of the study was to compare the perioperative and oncologic outcomes of patients who underwent surgery for colorectal cancer (CRC) performed using laparoscopy or using the Medtronic HugoTM Robotic-Assisted Surgery (RAS) system. Methods: This is a retrospective comparative single-center study of consecutive minimally invasive surgeries for CRC performed by two colorectal surgeons with extensive laparoscopic experience at the beginning of their robotic expertise. Patients were not selected for the surgical approach, but waiting lists and operating room availability determined whether the patients were in the robotic group or the laparoscopic group. The primary outcome was to compare 30-day postoperative complications according to the Clavien–Dindo classification and the Complication Comprehensive Index (CCI). The secondary outcomes included operating times, conversion rates, intraoperative complications, length of hospital stays (LOS), readmission rates, and short-term oncologic outcomes, such as the R0 resection, the number of lymph nodes harvested, the total mesorectal excision (TME) quality, and the circumferential resection margin (CRM). Results: Of the 109 patients, 52 underwent robotic and 57 laparoscopic CRC surgery. Patient demographic and clinical characteristics were similar in the two groups. There was no significant difference between the robotic and the laparoscopic groups regarding postoperative complications, the Clavien–Dindo classification, and the CCI. They also had similar operating times, conversion rates, intraoperative complications, LOSs, readmission rates, and short-term oncologic outcomes (the lymph nodes harvested, the R0 resection, TME quality, and CRM status). Conclusions: This study reports the largest cohort of CRC surgery performed using the Medtronic HugoTM RAS system and is the first comparative study with laparoscopy. The perioperative and oncologic outcomes were similar, demonstrating that the Medtronic HugoTM RAS system is safe and feasible for CRC as compared to laparoscopic surgery, even at the beginning of the robotic experience