Reversal of left-sided colostomy utilizing single-port laparoscopy a multicenter European audit and overview of the literature.

BACKGROUND: Stoma reversal surgery can result in considerable morbidity and even mortality. Feasibility of utilizing single-port laparoscopy through the stoma fenestration have been shown before. Aim of the present observational study is to evaluate multicenter experiences of single-port reversal of left-sided colostomy (SPRLC) throughout Europe and to provide an overview of available literature on this topic. METHODS: All patients undergoing SPRLC in four different teaching hospitals throughout Europe are included. Primary outcome was 30-day postoperative complication rate. Secondary outcomes were postoperative length of stay (LOS), single-port success rate and conversion rates. Appraisal of the available literature in PubMed was performed. RESULTS: Of 156 SPRLC procedures, 98.7% of them were technically successful and 71.8% were without postoperative complications. No postoperative mortality was encountered. Superficial site infection occurred in 14.7%, anastomotic leakage in 3.9% and major complications in 8.3%. Median LOS was 4.0 days (1-69), single-port success rate was 64.7%, 12.8% and 21.2% (33/154) were converted to an open and multiport laparoscopic procedure, respectively. Literature shows equally favorable results in 131 patients divided over 5 cohorts with morbidity ranging from 0 to 30.4% and mortality from 0 to 2.2% and median LOS of 4-8 days. CONCLUSION: This study confirms the safety, feasibility and favorable results of the use of single-port approach in the reversal of left-sided colostomy in different centers in Europe with laparoscopic experienced colorectal surgeons. The available literature on this topic support and show equally favorable results using single-port laparoscopy for left-sided colostomy reversal surgery.

Pregnancy after laparoscopic ventral mesh rectopexy: implications and outcomes.

AIM: Surgical management of rectal prolapse varies considerably. Most surgeons are reluctant to use ventral mesh rectopexy in young women until they have completed their family. The aim of the present study was to review outcomes of pregnancy following laparoscopic ventral mesh rectopexy from a tertiary referral centre over a 10-year period (2006-2016) and to review the impact on pelvic floor symptoms. METHOD: We undertook a retrospective review of a prospectively compiled database of patients who had undergone laparoscopic ventral rectopexy in a single centre over a 10-year period. Pelvic floor symptom scores (Vaizey for incontinence and Longo for obstructive defaecation) were collected at initial presentation (pre-intervention), post-intervention and after child birth. RESULTS: In all, 954 rectopexies were performed over this 10-year period. 225 (24%) patients were women and under 45 years of age (taken as an arbitrary cut-off for decreased likelihood of pregnancy). Eight (4%) of these patients became pregnant following rectopexy. The interval between rectopexy and delivery was 42 months (21-50). Six patients delivered live babies by elective lower segment caesarean section and two by spontaneous vaginal delivery. Six were first babies and two were second. No mesh related adverse outcome was reported. No difference in pelvic floor symptoms was demonstrated on comparison of post-rectopexy and post-delivery scores. CONCLUSION: This study provides the first description in the English language literature of safe delivery by elective lower segment caesarean section or spontaneous vaginal delivery following laparoscopic ventral mesh rectopexy. No adverse impact on pelvic floor related quality of life was detected.

Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) has become a well-established treatment for symptomatic high-grade internal rectal prolapse. The aim of this study was to identify proctographic criteria predictive of a successful outcome. METHODS: One hundred and twenty consecutive patients were evaluated from a prospectively maintained pelvic floor database. Pre- and post-operative functional results were assessed with the Wexner constipation score (WCS) and Fecal Incontinence Severity Index (FISI). Proctogram criteria were analyzed against functional results. These included grade of intussusception, presence of enterocele, rectocele, excessive perineal descent and the orientation of the rectal axis at rest (vertical vs. horizontal). RESULTS: Ninety-one patients completed both pre- and post-operative follow-up questionnaires. Median pre-operative WCS was 14 (range 10-17), and median FISI was 20 (range 0-61), with 28 patients (31%) having a FISI above 30. The presence of an enterocele was associated with more frequent complete resolution of obstructed defecation (70 vs. 52%, p = 0.02) and fecal incontinence symptoms (71 vs. 38%, p = 0.01) after LVMR. Patients with a more horizontal rectum at rest pre-operatively had significantly less resolution of symptoms post-operatively (p = 0.03). CONCLUSIONS: These data show that proctographic findings can help predict functional outcomes after LVMR. Presence of an enterocele and a vertical axis of the rectum at rest may be associated with a better resolution of symptoms.

No benefit of ultrasound-guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double-blind randomized controlled trial.

AIM: Advances in laparoscopic techniques combined with enhanced recovery pathways have led to faster recuperation and discharge after colorectal surgery. Peripheral nerve blockade using transversus abdominis plane (TAP) blocks reduce opioid requirements and provide better analgesia for laparoscopic colectomies than do inactive controls. This double-blind randomized study was performed to compare TAP blocks using bupivacaine with standardized wound infiltration with local anaesthetic (LA). METHOD: Seventy-one patients were randomized to receive either TAP block or wound infiltration. The TAP blocks were performed by experienced anaesthetists who used ultrasound guidance to deliver 40 ml of 0.25% bupivacaine post-induction into the transverse abdominis plane. In the control group, 40 ml of 0.25% bupivacaine was injected around the trocar and the extraction site by the surgeon. Both groups received patient-controlled analgesia (PCA) with intravenous morphine. Patients and nursing staff assessed pain scores 6, 12, 24 and 48 h after surgery. The primary outcome was overall morphine use in the first 48 h. RESULTS: Of the 71 patients, 20 underwent a right hemicolectomy and 51 a high anterior resection. The modified intention-to-treat analysis showed no significant differences in overall morphine use [47.3 (36.2-58.5) mg vs 46.7 (36.2-57.3) mg; mean (95% CI), P = 0.8663] in the first 48 h. Pain scores were similar at 6, 12, 24 and 48 h. No differences were found regarding time to mobilization, resumption of diet and length of hospital stay. CONCLUSION: In elective laparoscopic colectomies, standardized wound infiltration with LA has the same analgesic effect as TAP blocks post-induction using bupivacaine at 48 h.

Sacral neuromodulation for persistent faecal incontinence after laparoscopic ventral rectopexy for high-grade internal rectal prolapse.

AIM: Internal rectal prolapse is recognized as an aetiological factor in faecal incontinence. Patients found to have a high-grade internal rectal prolapse on routine proctography are offered a laparoscopic ventral rectopexy after failed maximum medical therapy. Despite adequate anatomical repair, faecal incontinence persists in a number of patients. The aim of this study was to evaluate the outcome of sacral neuromodulation in this group of patients. METHOD: Between August 2009 and January 2012, 52 patients who underwent a laparoscopic ventral rectopexy for faecal incontinence associated with high-grade internal rectal prolapse had persistent symptoms of faecal incontinence and were offered sacral neuromodulation. Symptoms were evaluated before and after the procedure using the Fecal Incontinence Severity Index (FISI) and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: Temporary test stimulation was successful in 47 (94%) of the patients who then underwent implantation of a permanent pulse generator. The median FISI score 1 year after sacral neuromodulation was lower than the median score before [34 (28-59) vs. 19 (0-49); P < 0.01], indicating a significant improvement in faecal continence. Quality of life (GIQLI) was significantly better after starting sacral neuromodulation [78 (31-107) vs. 96 (55-129); P < 0.01]. CONCLUSION: Patients may benefit from sacral neuromodulation for persisting faecal incontinence after laparoscopic ventral rectopexy.

Temporary sacral neuromodulation under local anaesthesia using new anatomical reference points.

BACKGROUND: Prior to implantation of an expensive sacral nerve stimulator, a 'screening phase' is undertaken. This report examines the feasibility of temporary sacral neuromodulation under local anaesthesia in an outpatient setting. We report on our technique, results and patient satisfaction. METHODS: Percutaneous nerve evaluation was performed in 184 patients using a new set of reference points and local anaesthesia to guide insertion of a test wire without the need for fluoroscopy in an outpatient setting. Three bony landmarks were used: tip of the coccyx, sacro-coccygeal joint and posterior superior iliac spine. The technical success was defined as stimulation in the perineal/anal area at amperages <6 mAmp. A consecutive cohort of 24 patients was asked to grade their pain and satisfaction regarding the procedure. RESULTS: Successful placement of the test wire was accomplished in 171 patients (93 %). Twelve patients required placement under fluoroscopy due to lack of sensation during stimulation (N = 7) procedural pain (N = 4) or failure to identify S3 or S4 (N = 2). There were two lead infections, one lead dislocation and one lead fracture. 22 of 24 patients (92 %) would recommend the procedure under local anaesthesia to other patients. CONCLUSIONS: Temporary sacral neuromodulation can be reliably performed in a more practical, less expensive outpatient setting under local anaesthesia without adversely influencing test outcome.

Local recurrence after stenting for obstructing left-sided colonic cancer.

BACKGROUND: Self-expanding metallic stents (SEMS) may be used in acute obstructing left-sided colonic cancers to avoid high-risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long-term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection. METHODS: A consecutive prospective cohort of patients admitted with obstructing left-sided colonic cancer between 2006 and 2012 was analysed. The decision to stent as a bridge to surgery or to perform emergency surgery was made by the on-call consultant colorectal surgeon in conjunction with a consultant interventional radiologist; when appropriate, they performed the stent procedure together. Primary outcomes were local and distant recurrence, and overall survival. Secondary outcomes were postoperative complications, in-hospital mortality, proportion of procedures undertaken laparoscopically, and anastomosis and stoma rates. RESULTS: In total, 105 patients with obstructing left-sided colonic cancer were treated with curative intent; 62 were treated with SEMS as a bridge to surgery and 43 had emergency resection. In patients aged 75 years or less, stenting and delayed surgery was associated with a higher local recurrence rate compared with emergency surgery at the end of follow-up (32 versus 8 per cent; P = 0·038). This did not translate into a significant difference in overall survival. CONCLUSION: SEMS was associated with an increased local recurrence rate.

Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colorectal surgery.

BACKGROUND: With the implementation of multimodal analgesia regimens in fast-track surgery programmes, non-steroidal anti-inflammatory drugs (NSAIDs) are being prescribed routinely. However, doubts have been raised concerning the safety of NSAIDs in terms of anastomotic healing. METHODS: Data on patients who had undergone primary colorectal anastomosis at two teaching hospitals between January 2008 and December 2010 were analysed retrospectively. Exact use of NSAIDs was recorded. Rates of anastomotic leakage were compared between groups and corrected for known risk factors in both univariable and multivariable analyses. RESULTS: A total of 795 patients were divided into four groups according to NSAID use: no NSAIDs (471 patients), use of non-selective NSAIDs (201), use of selective cyclo-oxygenase (COX) 2 inhibitors (79), and use of both selective and non-selective NSAIDs (44). The overall leak rate was 9.9 per cent (10.0 per cent for right colonic, 8.7 per cent for left colonic and 12.4 per cent for rectal anastomoses). Known risk factors such as smoking and use of steroids were not significantly associated with anastomotic leakage. Stapled anastomosis was identified as an independent predictor of leakage in multivariable analysis (odds ratio (OR) 2.22, 95 per cent confidence interval 1.30 to 3.80; P = 0.003). Patients on NSAIDs had higher anastomotic leakage rates than those not on NSAIDs (13.2 versus 7.6 per cent; OR 1.84, 1.13 to 2.98; P = 0.010). This effect was mainly due to non-selective NSAIDs (14.5 per cent; OR 2.13, 1.24 to 3.65; P = 0.006), not selective COX-2 inhibitors (9 per cent; OR 1.16, 0.49 to 2.75; P = 0.741). The overall mortality rate was 4.2 per cent, with no significant difference between groups (P = 0.438). CONCLUSION: Non-selective NSAIDs may be associated with anastomotic leakage.