Synthetic versus biological mesh-related erosion after laparoscopic ventral mesh rectopexy. A systematic review

Purpose: This review reports the incidence of mesh-related erosion after ventral mesh rectopexy to determine whether any difference exists in the erosion rate between synthetic and biological mesh. Methods: A systematic search of the MEDLINE and the Ovid databases was conducted to identify suitable articles published between 2004 and 2015. The search strategy capture terms were laparoscopic ventral mesh rectopexy, laparoscopic anterior rectopexy, robotic ventral rectopexy, and robotic anterior rectopexy. Results: Eight studies (3,956 patients) were included in this review. Of those patients, 3,517 patients underwent laparoscopic ventral rectopexy (LVR) using synthetic mesh and 439 using biological mesh. Sixty-six erosions were observed with synthetic mesh (26 rectal, 32 vaginal, 8 recto-vaginal fistulae) and one (perineal erosion) with biological mesh. The synthetic and the biological mesh-related erosion rates were 1.87% and 0.22%, respectively. The time between rectopexy and diagnosis of mesh erosion ranged from 1.7 to 124 months. No mesh-related mortalities were reported. Conclusion: The incidence of mesh-related erosion after LVR is low and is more common after the placement of synthetic mesh. The use of biological mesh for LVR seems to be a safer option; however, large, multicenter, randomized, control trials with long follow-ups are required if a definitive answer is to be obtained

Laparoscopic Treatment of Bouveret's Syndrome Presenting as Acute Pancreatitis

Gastric outlet obstruction as a result of gallstone (Bouveret's syndrome) is a rare but serious complication of cholelithiasis. Although patients present with persistent vomiting, colicky epigastric pain and dehydration, the clinical features of the Bouveret's syndrome are not pathognomonic. Due to its rarity, the diagnosis and treatment represent a challenge for the surgeon. In most of the reported cases, the diagnosis was made at the time of laparotomy. We report an unusual clinical presentation of Bouveret's syndrome with mild acute pancreatitis that was treated laparoscopically. To our knowledge, this is the first described case. Cause, clinical presentation, methods of diagnosis, and options for management of Bouveret's syndrome are also discussed

Transanal minimally invasive surgery for rectal lesions

Background and Objectives: Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery (TEM). The authors report their experience with TAMIS for the treatment of mid and high rectal tumors. Methods: From November 2011 through May 2016, 31 patients (21 females, 68%), with a median age of 65 years who underwent single-port TAMIS were prospectively enrolled. Mean distance from the anal verge of the rectal tumors was 9.5 cm. Seventeen patients presented with T1 cancer, 10 with large adenoma, 2 with gastrointestinal stromal tumor (GIST) and 2 with carcinoid tumor. Data concerning demographics, operative procedure and pathologic results were analyzed. Results: TAMIS was successfully completed in all cases. In 4 (13%) TAMIS was converted to standard Park’s transanal technique. Median postoperative stay was 3 days. The overall complication rate was 9.6%, including 1 urinary tract infection, 1 subcutaneous emphysema, and 1 hemorrhoidal thrombosis. TAMIS allowed an R0 resection in 96.8% of cases (30/31 cases) and a single case of local recurrence after a large adenoma resection was encountered. Conclusion: TAMIS is a safe technique, with a short learning curve for laparoscopic surgeons already proficient in single-port procedures, and provides effective oncological outcomes compared to other techniques

Iatrogenic Rectal Perforation During Operative Colonoscopy: Closure With Endoluminal Clips

The risk of perforation during diagnostic or operative colonoscopy can be as high as 2%. Despite conservative treatment being acceptable, the closure of the perforation is usually mandatory, and surgery (either open or laparoscopic) is commonly advocated as rescue therapy. Currently, with the availability of the Endoclip, endoscopists are able to manage iatrogenic perforations avoiding surgery. Clip placement, if necessary, will not delay surgery and might help the surgeon find the site of perforation. However, data in the literature are scant, especially for the closure of large colonic defects. Endoscopic repair using Endoclip devices for a large high rectal perforation following polypectomy is described herein

Routine pathology examination in the era of value-based healthcare: the case of haemorrhoids specimens

Routine pathologic examination of specimens is a common practice with ill-defined value. The present study is the first to investigate the incidence and cost of incidental microscopic lesions in both haemorrhoidectomy and stapled haemorrhoidopexy specimens. Pathological reports of specimens obtained from haemorrhoidectomy and stapled haemorrhoidopexy procedures performed from January 2003 to May 2017 were analysed. Specimens resulting from patients treated for any disease other than haemorrhoids alone were excluded from the study. Unexpected diagnoses in the pathological report were defined as incidental diagnoses. A cost analysis was then performed. In the considered period we performed a total of 3017 procedures complying with our criteria. We found 65 (2.15%) unexpected lesions. Of the incidental diagnosis, 30 (0.99%) altered either the follow-up or the treatment. The incidences of both findings were extremely higher in haemorrhoidectomies specimens (p < 0.0001). We estimated that the cost of 14 years of routine pathological examination of haemorrhoids specimens was 133,351.4 euros, each consequential incidental diagnosis costing 4445.03 euros. The incidence of unexpected lesions in routine pathologic examination of haemorrhoidectomy and haemorrhoidopexy specimens is low but not negligible. The vast majority of incidental findings were found among haemorrhoidectomy specimens. Even though the real value of routine pathological examination of haemorrhoids specimens is still uncertain, from a clinical standpoint we were glad to suggest each patients the best follow-up and/or treatment. Future studies should assess preoperative patient's risk stratification and careful intraoperative macroscopic inspection strategies for selective pathology examination of haemorrhoids specimens

minimally invasive surgery for rectal prolapse laparoscopic procedures

Surgical treatment of external rectal prolapse, internal intussusception (or internal rectal prolapse), and rectocele is still a challenging clinical problem in the field of colorectal surgery [1, 2]. These conditions may be associated with various pelvic floor disorders, including motility and morphological/functional disorders, ranging from constipation to fecal incontinence, thus significantly affecting the patients' quality of life [3, 4]. A large variety of surgical procedures exists. The literature offers abundant publications, the main problem for an informed decision on the perfect surgical technique being an often large variability of patients' selection, diagnostic assessment and variation within the same surgical technique and materials. As a consequence, the colorectal surgeon still lacks a standardized diagnostic assessment as well as a clear ideal surgical technique [5]. Perineal procedures, such as Delorme's or perineal rectosigmoidectomy or stapled transanal rectal prolapse resection, are indicated for elderly and frail patients, who are not fit for an intervention under general anesthesia, but they have poor efficacy in terms of functional outcomes and recurrence, which may be up to 26 % [6], and also an increasing risk for postoperative incontinence [7]. Abdominal procedures, on the other side, either open or laparoscopic, employing rectal mobilization and fixation, colonic resection or a combination of both, show lower recurrence rates and better functional results, but may cause postoperative worsening of constipation, mostly due to the full rectal mobilization and the consequent possible autonomic nerve injury, which is responsible for dysmotility and impaired evacuation [8]. Laparoscopic ventral mesh recto(colpo)pexy has been introduced in order to obtain good results in terms of functional outcome of the abdominal procedures while avoiding postoperative constipation and incontinence, offering the advantages of anterolateral mobilization, mesh repair and of the laparoscopic approach compared to the open [9]

Correction to: Interstitial cells of Cajal increased in patients with rectal prolapse

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Perirectal hematoma after stapled surgery for hemorrhoidal prolapse and obstructed defecation syndrome: case series management to avoid panic-guided treatment

Perirectal hematoma (PH) is one of the most feared complications of stapling procedures. Literature reviews have reported only a few works on PH, most of them describing isolated treatment approaches and severe outcomes. The aim of this study was to analyze a homogenous case series of PH and to define a treatment algorithm for huge postoperative PHs. A retrospective analysis of a prospective database of three high-volume proctology units was performed between 2008 and 2018, and all PH cases were analyzed. In all, 3058 patients underwent stapling procedures for hemorrhoidal disease or obstructed defecation syndrome with internal prolapse. Among these, 14 (0.46%) large PH cases were reported, and 12 of these hematomas were stable and treated conservatively (antibiotics and CT/laboratory test monitoring); most of them were resolved with spontaneous drainage. Two patients with progressive PH (signs of active bleeding and peritonism) were submitted to CT and arteriography to evaluate the source of bleeding, which was subsequently closed by embolization. This approach helped ensure that no patients with PH were referred for major abdominal surgery. Most PH cases are stable and treatable with a conservative approach, evolving with self-drainage. Progressive hematomas are rare and should undergo angiography with embolization to minimize the possibility of major surgery and severe complications

Aryl Hydrocarbon Receptor-Induced Signals Up-regulate IL-22 Production and Inhibit Inflammation in the Gastrointestinal Tract

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