Safe implementation of robotic right colectomy with intracorporeal anastomosis.

The robotic platform can overcome technical difficulties associated with laparoscopic colon surgery. Transitioning from laparoscopic right colectomy with extracorporeal anastomosis (ECA) to robotic right colectomy with intracorporeal anastomosis (ICA) is associated with a learning phase. This study aimed at determining the length of this learning phase and its associated morbidity. We retrospectively analyzed all laparoscopic right colectomies with ECA (n = 38) and robotic right colectomies with ICA (n = 67) for (pre)malignant lesions performed by a single surgeon between January 2014 and December 2020. CUSUM-plot analysis of total procedure time was used for learning curve determination of robotic colectomies. Non-parametric tests were used for statistical analysis. Compared to laparoscopy, the learning phase robotic right colectomies (n = 35) had longer procedure times (p < 0.001) but no differences in anastomotic leakage rate, length of stay or 30-day morbidity. Conversion rate was reduced from 16 to 3 percent in the robotic group. This study provides evidence that robotic right colectomy with ICA can be safely implemented without increasing morbidity.

Belgian consensus guideline on the management of hemorrhoidal disease.

Introduction: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Long-term results after excision haemorrhoidectomy versus stapled haemorrhoidopexy for prolapsing haemorrhoids; a Belgian prospective randomized trial.

PURPOSE: To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM). METHODS: In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months. RESULTS: Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P < 0.0001). Healing time was shorter after PPH (P < 0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P < 0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM. CONCLUSIONS: Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haemorrhoidal disease, needing further surgery.

Artificial anal sphincter: prospective clinical and manometric evaluation.

INTRODUCTION: Artificial anal sphincter has been proposed in severe anal incontinence when local treatment is unsuitable or has failed. The outcome after implantation of this newly developed device has not yet been determined. METHODS: Twenty-four consecutive patients (7 men; median age, 44; standard deviation, 18; range, 14-80 years) implanted since May 1996 for a minimum of six months at three centers were prospectively evaluated. Continence (scoring system, 0 (normal) to 120 (complete incontinence)), rectal emptying, and general satisfaction were assessed clinically and at anal manometry preoperatively and postoperatively at a six-month interval. The causes of incontinence included anal trauma (9 cases), neuropathy (6 cases), neurologic disorders (4 cases), congenital malformations (3 cases), and prolapse (2 cases). Median duration of incontinence was 7.5 (standard deviation, 8) years. Stomas pre-existed in two cases and was created at implantation in one. RESULTS: Median follow-up was 20 (standard deviation, 8; range, 10-35) months. Seven patients had their devices explanted, and reimplantation was successfully performed in three of these cases. At the end of follow-up, 20 (83 percent) patients had an implanted activated device. Fecal incontinence score dropped significantly from a median 106 (standard deviation, 13) preoperatively to 19 (standard deviation, 32), 25 (standard deviation, 29), and 25 (standard deviation, 25) at six months, one year, and the end of follow-up, respectively (P<0.0001). Minor and major emptying difficulties occurred in seven and two patients, respectively. A high degree of satisfaction was achieved at the end of follow-up in 18 (75 percent) of the total series. Median anal pressures at rest on manometry increased significantly from 28 (standard deviation, 17; range, 5-76) mm Hg preoperatively to 60 (standard deviation, 17; range, 38-96) mmHg with a closed cuff at the end of follow-up. These pressures dropped to 30 (standard deviation, 16; range, 9-65) mm Hg with an open cuff, and reocclusion time lasted a median of 4.6 minutes (standard deviation, 3 minutes; range, 38 seconds to 10 minutes). CONCLUSION: Artificial anal sphincter provided prolonged and reasonably good functional results in severe incontinence, reproducing an efficient sphincteric mechanism and allowing satisfactory anal occlusion and rectal emptying in approximately 75 percent of cases in this study. The definitive explantation rate was kept low by careful patient selection and appropriate surgical and perioperative management.

Difficult fistulae.

Fistula in ano is a common disorder. The goals of treatment are to cure the fistula with minimal loss of sphincter function and with minimal healing time. Fortunately about 90% of fistulae are simple and obey Goodsall's rule. These fistulae are easily treated by the "lay-open" technique. Treatment can however become much more difficult with increasing complexity of fistula tracks, higher internal opening with major sphincter involvement, atypical and secondary tracks or at recurrence. Understanding of the anatomy and the pathogenesis of fistulae is mandatory to identify the fistula tracks and the internal opening and to tailor the treatment accordingly. Endoanal flap repairs and the use of setons are most widely accepted for the treatment of difficult fistulae but many other options exist. Underlying factors or associated diseases such as inflammatory bowel, AIDS and other sexually transmitted diseases, carcinoma, radiotherapy, hidroadenitis or other obscure infections may influence the final outcome and often demand a specific approach.

Posttraumatic rupture of the thoracic aorta.

Ten patients with traumatic lesions of the thoracic aorta were seen in a hospital. Most were victims of traffic accidents and presented severe associated lesions along with their vascular trauma. We found that the vascular injuries were clinically manifest in only a minority of patients. The remaining ruptures were discovered through CT-scanning of the mediastinum or angiography. We believe that in every major trauma victim aortic lesions should be actively sought for by complimentary examinations to guarantee maximum survival of the patients.

Endometriosis of the appendix.

Endometriosis has been encountered in different sites of the gastrointestinal tract. Involvement of the vermiform appendix, however, is rather unusual. Two cases of appendiceal endometriosis are reported in the present study: one patient had symptoms simulating acute appendicitis; in another patient it was an incidental finding during pelvic surgery. There are no clinical signs and findings pathognomonic of endometriosis of the appendix, but the condition may present as appendicitis. At surgery, the diagnosis can only be suspected when it is associated with obvious genital endometriosis. Correct diagnosis is established by microscopic examination of the lesion. Symptomatic endometriosis of the appendix will be cured by appendectomy.