The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitisA and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitisB in perforated diverticulitis (NTR2037)

Background: Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy. The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). Methods/Design: In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and powe

The transanal endoscopic microsurgery procedure: standards and extended indications.

Transanal endoscopic microsurgery (TEM) was developed in the early 1980s as a minimally invasive technique allowing the resection of benign rectal adenomas. For this indication, TEM was reported to be safe and effective and even exceeded the results compared to classical local excision. Unsurprisingly, the indication expanded to small rectal cancer. There is still much debate, though, whether it is oncologically safe to perform TEM for rectal cancer. Much has been published about the need for proper patient selection, i.e. patients presenting a low-risk T1 rectal cancer seem to be the most adequate subgroup for this technique. Nevertheless, TEM remains controversial concerning high-risk T1 rectal adenocarcinomas and deeper infiltrating tumors. Several retrospective case series and a small prospective study suggest that radiochemotherapy before local excision reduces recurrence to a level comparable with classic radical surgery (total mesorectal excision). However, these studies are collectively limited, and prospective data from larger multicenter trials are awaited. Reports about functional results after TEM have shown that the procedure has no permanent impact on anorectal function. Even if transient anal resting pressure weakening has been repeatedly described, patients do not suffer from any long-term functional sequelae. Nor do they complain of quality of life impairment

Freehand endoscopic ultrasound-guided transrectal drainage of diverticulitis-associated abscess with electrocautery-enhanced lumen-apposing metal stent under spinal anesthesia.

Complicated diverticulitis occurs in 12 % of all diverticulitis cases. Radiological drainage is the first-line therapy in cases of large diverticulitis-associated abscess. However, the pelvic location renders the radiological access challenging. Lower endoscopic ultrasound (EUS)-guided drainage, using an electrocautery-enhanced lumen-apposing metal stent (LAMS), is a feasible and safe alternative method for drainage of pelvic collections. We present a case of a diverticulitis-associated abscess successfully treated using EUS-guided LAMS. [...

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited.

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed

Innovations en Chirurgie colorectale. Que retenir de 2015?

Cette année aura été marquée par le début de la chirurgie colorectale assistée par robot au sein des Cliniques universitaires Saint-Luc. La chirurgie assistée par robot est une technique chirurgicale nouvelle qui a été mise au point pour pallier les limitations techniques de la chirurgie laparoscopique. En effet, contrairement aux instruments rectilignes et rigides de la laparoscopie classique, les bras du robot ainsi que ses instruments permettent des mouvements imitant parfaitement ceux du poignet et de la main du chirurgien. Associées à une vision 3D du champ opératoire, à un grossissement de 10 fois et à un filtrage du tremblement physiologique, ces caractéristiques, et d’autres encore, sont la clé d’une chirurgie mini-invasive extrêmement précise et sûre.[Colorectal surgery in the robotic era] The year 2015 has been marked by the initiation of robotic-assisted colorectal surgery at the Cliniques universitaires Saint-Luc. Robotic surgery is a new surgical technology, which attempts to overcome the technical limitations of laparoscopic surgery. Contrary to the rectilinear and rigid instruments used in classical laparoscopy, the robot’s arms and instruments allow for intuitive movements that perfectly mimic those of the surgeon’s wrist and hand. Along with the 3D magnified vision of the operating field and filtering of physiological tremor, these features in addition to others are key to the precision and safety of minimally invasive surgery

Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements

BACKGROUND: This study aimed to review the authors' 16-year experience with transanal endoscopic microsurgery (TEM). Mortality, morbidity, recurrence rate, and functional outcome were assessed. New indications and technical improvements are presented. METHODS: From November 1991 to August 2008, 123 patients (72 men and 51 women; median age, 68 years; range, 21-91 years) underwent TEM for excision of 105 adenomas with low- or high-grade dysplasia, 9 invasive adenocarcinomas (5 curative and 4 palliative resections), 2 neuroendocrine tumors, and 2 extramucosal lesions. Five additional patients had excisional biopsies, allowing staging after previous endoscopic resection. Most of the resections were full-thickness rectal resections using electrocautery or, more recently, the Harmonic scalpel. The latest mucosectomies were performed using the endoscopic submucosal dissection (ESD) technique. In addition, nontumoral indications included pelvic abscess (7 patients) and rectal strictures, which were either anastomotic or chemical. Pelvic abscesses were drained transrectally, whereas rectal stenoses were treated by strictureplasty. Foreign object retrieval and collagen plug placement for anal fistulas were performed using TEM in three patients. RESULTS: No mortality occurred. One intraoperative rectal perforation required conversion to laparotomy. The postoperative complications included one pneumoperitoneum, which was treated medically, and one rectal perforation requiring Hartmann's procedure. In the polyp subgroup, six patients (6/91, 7%) experienced local recurrence. Pelvic abscesses were successfully treated, and stenosis did not recur after strictureplasty. Anorectal manometry showed functional alterations without significant clinical impact. CONCLUSIONS: The findings showed TEM to be a safe and effective procedure for local excision of rectal lesions with a low recurrence rate and minimal consequences in terms of anorectal function. In addition, TEM proved to be feasible and effective for pelvic abscess drainage and rectal stenosis treatment. New technologies such as the Harmonic scalpel and ESD increase the precision already offered by this approach

Neoplastic thrombosis of the inferior mesenteric vein: a anatomo-radiological confrontation

info:eu-repo/semantics/publishe

Case report of multiple rectal neuroendocrine tumors in a context of ulcerative colitis.

Neuroendocrine tumors (NETs) of the rectum are rare, with an estimated incidence of 0.1% of all colorectal cancers. However, it is crucial to diagnose NET, particularly in patients with ulcerative colitis, who seem to have a higher risk of cancerization according to recent studies, given the aggressiveness and poor prognosis of these tumors. We report the case of a 54-year-old man who developed multiple rectal NETs (approximately 10), measuring 1-6 mm, only 2 years after a primary diagnosis of ulcerative colitis. In the literature, all reported cases of NETs present patients with a long history of several years of inflammatory bowel disease; however, very little literature exists on this subject. Herein, we discussed the outcomes and a literature review of the pathology, prognosis, and management of NETs. Despite advances in research on rectal NETs, many aspects about the disease remain unclear, partly due to its rarity

Single center experience with salvage surgery for chronic pelvic sepsis

Chronic pelvic sepsis eventually requires salvage surgery in half of all patients. The goal of surgery is to resolve pelvic inflammation while restoring intestinal continuity. Our salvage procedure achieves this by bringing a healthy conduit into the pelvis and creating an anastomosis beyond the source of sepsis. We aimed to review our single center experience with this procedure for the treatment of chronic pelvic sepsis. All patients requiring the procedure from 2010 to 2018 were retrospectively reviewed using a prospective database. Morbidity and mortality were evaluated, and restoration of bowel continuity at 1-year rate was the endpoint. Twenty patients were included. The main indication was pelvic sepsis after anastomotic leak (AL). The median age was 60 (42–86) years and the median BMI was 26 (18–37) kg/m2. The median time carrying a stoma before the intervention was 15 months, and median time to intervention was 32 months. All patients had a diverting stoma. There were no death and overall morbidity reached 60%, and AL rate was 10%. At 1 year, 70% of the patients had their intestinal continuity restored. In expert hands, salvage surgery for chronic pelvic sepsis has acceptable morbidity rates, an acceptable rate of AL, and a bowel restoration success rate 70% at 1 year, and is a valuable option for patients failing conservative treatment