Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases.

AIM: This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA). METHODS: All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included. RESULTS: From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump < 7.5 cm in length as the only independent risk factor for long-term persistent stoma. Among stoma-free patients, low anterior resection syndrome (LARS) score was ≤ 20 (normal) in 43%, between 21 and 29 (minor LARS) in 33% and ≥ 30 (major LARS) in 24% of the patients. CONCLUSION: HR can be recommended in patients following a failed CRA or CAA. It permits 78% of patients to be free of stoma. A short length of the remnant rectal stump is the only predictive factor of persistent stoma in these patients.

Hospital stay for temporary stoma closure is shortened by C-reactive protein monitoring: a prospective case-matched study.

BACKGROUND: C-reactive protein (CRP) has been suggested as a satisfactory early marker of postoperative complications after colorectal surgery. The aim of this study was to assess the impact of a CRP monitoring-driven discharge strategy, after stoma reversal following laparoscopic sphincter-saving surgery for rectal cancer. METHODS: Eighty-eight patients who had stoma reversal between June 2016 and April 2018 had CRP serum level monitoring on postoperative day (POD) 3 and, if necessary, on POD5. Patients were discharged on POD4 if the CRP level was < 100 mg/L. Patients were matched [according to age, gender, body mass index, neoadjuvant pelvic irradiation, type of anastomosis (stapled or manual), and adjuvant chemotherapy] to 109 identical control patients who had stoma reversal between 2012 and 2016 with the same postoperative care but without CRP monitoring. RESULTS: Postoperative 30-day overall morbidity [CRP group: 12/88 (14%) vs controls: 11/109, (10%), p = 0.441] and severe morbidity rates (i.e. Dindo 3-4) [CRP group: 2/88 (2%) vs controls: 2/109 (2%), p = 0.838] were similar between groups. Mean length of stay was significantly shorter in the CRP group (CRP group: 4.6 ± 1.3 vs controls: 5.8 ± 1.8 days; p < 0.001). Discharge occurred before POD5 in 59/88 (67%) CRP patients vs 15/109 (14%) controls (p < 0.001). The unplanned rehospitalization rate [CRP group: 6/88 (7%) vs controls: 4/109 (4%), p = 0.347] was similar between groups. CONCLUSIONS: In patients having temporary stoma closure after laparoscopic surgery for rectal cancer, postoperative CRP monitoring is associated with a significant shortening of hospital stay without increasing morbidity or rehospitalization rates.

What is the outcome for patients undergoing more than two ileocolonic resections for recurrent Crohn's disease? A comparative study of 569 consecutive procedures.

AIM: To assess the outcome for patients undergoing repeated ileocolonic resection for recurrent Crohn's disease (CD). METHOD: All patients undergoing ileocolonic resection for terminal ileal CD between 1998 and 2016 in our tertiary care centre were retrospectively reviewed. RESULTS: Between 1998 and 2016, 569 ileocolonic resections were performed for CD: 403 of these were primary resections (1R, 71%), 107 second resections (2R, 19%) and 59 were third (or more) resections (> 2R, 10%). The laparoscopic approach rate was significantly less in the > 2R group (20/59, 34%) compared with the 2R (71/107, 66%; P = 0.002) and 1R (366/403, 91%) groups. However, conversion to an open approach did not show any difference between the three groups [1R group 46/366 (13%) vs 2R group 14/71 (20%) vs > 2R group 3/20 (15%); 1R vs > 2R P = 0.750; 2R vs > 2R P = 0.633]. Postoperative morbidity was significantly increased in the > 2R (28/59, 52%) group compared with the 1R group (115/403, 29%; P < 0.001) but showed no difference compared with the 2R group (43/107, 40%; P = 0.365). There was no difference between the groups in the incidence of severe postoperative morbidity (Clavien-Dindo ≥ 3) [1R group n = 24 (6%); 2R group n = 6 (6%); > 2R group n = 4, 7%; 1R vs > 2R P = 0.865, 2R vs > 2R P = 0.761]. CONCLUSION: Although the overall morbidity rate was higher, repeated surgery for recurrent CD in patients undergoing three or more ileocolonic resections was not associated with an increased risk of severe postoperative morbidity in our series.

Redo ileal pouch-anal anastomosis: outcomes from a case-controlled study.

AIM: To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA. METHOD: This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index. RESULTS: Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51  (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function. CONCLUSION: The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.

Is trans-anal total mesorectal excision really safe and better than laparoscopic total mesorectal excision with a perineal approach first in patients with low rectal cancer? A learning curve with case-matched study in 68 patients.

AIM: To compare the learning curve for trans-anal total mesorectal excision (TATME) with laparoscopic TME started by a perineal approach (LTME). METHOD: The first 34 consecutive patients who underwent TATME for low rectal cancer were matched with LTME (performed by the same surgeon) for gender, body mass index and chemoradiation. RESULTS: Thirty-four patients undergoing TATME (23 men; 58 ± 14 years) were matched with 34 undergoing LTME (23 men; 59 ± 13 years). Intra-operative complications occurred more frequently during TATME (21%) than LTME (6%), but this difference was not significant (P = 0.07). The complications of TATME included rectal (n = 4), bladder (n = 1) and vaginal (n = 1) injury and bleeding (n = 1). Length of stay and postoperative overall and major morbidities were similar between groups. Early symptomatic anastomotic leakage (AL) occurred in 1/34 TATME and 5/34 LTME (15%; P = 0.02) procedures. Asymptomatic AL occurred in four TATME (12%) and four LTME (12%, P = 1). Thus, the overall rate of AL was 5/34 (15%) for TATME vs 9/34 (26%) for LTME (P = 0.4). No significant difference between the two groups was noted with regard to tumour, number of harvested and positive lymph nodes, R1 resection rate or completeness of the mesorectum. Metastatic recurrence was similar between groups (15% vs 18%, P = 0.7), but follow-up was shorter after TATME (13 ± 6 months) than after LTME (25 ± 14 months; P < 0.0001). CONCLUSION: The TATME learning curve seems to be associated with a significant rate of intra-operative complications. Because no significant benefit has been reported to date, more evidence is needed before TATME can be considered as a better approach than laparoscopic TME with a perineal approach first in patients with low rectal cancer.

Transversus abdominis plane (TAP) block in laparoscopic colorectal surgery improves postoperative pain management: a meta-analysis.

AIM: Transversus abdominis plane (TAP) block is a locoregional anaesthesia technique of growing interest in abdominal surgery. However, its efficacy following laparoscopic colorectal surgery is still debated. This meta-analysis aimed to assess the efficacy of TAP block after laparoscopic colorectal surgery. METHOD: All comparative studies focusing on TAP block after laparoscopic colorectal surgery have been systematically identified through the MEDLINE database, reviewed and included. Meta-analysis was performed according to the Mantel-Haenszel method for random effects. End-points included postoperative opioid consumption, morbidity, time to first bowel movement and length of hospital stay. RESULTS: A total of 13 studies, including 7 randomized controlled trials, were included, comprising a total of 600 patients who underwent laparoscopic colorectal surgery with TAP block, compared with 762 patients without TAP block. Meta-analysis of these studies showed that TAP block was associated with a significantly reduced postoperative opioid consumption on the first day after surgery [weighted mean difference (WMD) -14.54 (-25.14; -3.94); P = 0.007] and a significantly shorter time to first bowel movement [WMD -0.53 (-0.61; -0.44); P < 0.001] but failed to show any impact on length of hospital stay [WMD -0.32 (-0.83; 0.20); P = 0.23] although no study considered length of stay as its primary outcome. Finally, TAP block was not associated with a significant increase in the postoperative overall complication rate [OR = 0.84 (0.62-1.14); P = 0.27]. CONCLUSION: Transversus abdominis plane (TAP) block in laparoscopic colorectal surgery improves postoperative opioid consumption and recovery of postoperative digestive function without any significant drawback.

Anastomotic stenosis after coloanal, colorectal and ileoanal anastomosis: what is the best management?

AIM: To assess the results of treatment for colorectal (CRA), coloanal (CAA) or ileal pouch-anal (IPAA) anastomotic stenosis (AS). METHOD: All patients operated on for AS from 1995 to 2014 were included. Success was defined as the absence of an additional surgical procedure for AS during 12 months after the last procedure and the absence of a stoma at the end of follow-up. RESULTS: Fifty consecutive patients presenting with AS after CRA (n = 16, 32%), CAA (n = 18, 36%) or IPAA (n = 16, 32%), performed for colorectal cancer (n = 28, 56%), familial adenomatous polyposis (n = 5, 10%), inflammatory bowel disease (n = 8, 16%), diverticulitis (n = 4, 8%), benign colorectal neoplasia (n = 3, 6%) or other (n = 2, 4%) underwent a total of 99 procedures including digital (n = 14, 14%), instrumental (n = 38, 38%) or endoscopic dilatation (n = 5, 5%), transanal AS stricturoplasty (n = 9, 10%), transanal circular stapler resection (n = 11, 11%) or transabdominal redo-anastomosis (n = 22, 22%). Overall the per-procedure success rate was 53% (52/99). Success rates were 36% (5/14) for digital dilatation, 40% (15/38) for instrumental dilatation, 20% (1/5) for endoscopic dilatation, 64% (7/11) for circular stapler resection, 89% (8/9) for stricturoplasty and 73% (16/22) for transabdominal redo-anastomosis. After a mean follow-up of 46 months, 42/50 (84%) patients had treatment that was considered successful. Multivariate analysis identified redo-anastomosis [OR = 5.1 (95% CI: 1.4-18.7), P = 0.003] as the only independent prognostic factor for success. CONCLUSION: AS should be managed according to a step-up strategy. Conservative procedures are associated with acceptable success rates. If these fail, transabdominal redo-anastomosis is associated with the highest probability of success.

Oncological impact of anastomotic leakage after laparoscopic mesorectal excision.

BACKGROUND: The effect of anastomotic leakage on oncological outcomes after total mesorectal excision (TME) is controversial. This study aimed to assess the influence of symptomatic and asymptomatic anastomotic leakage on oncological outcomes after laparoscopic TME. METHODS: All patients who underwent restorative laparoscopic TME for rectal adenocarcinoma with curative intent from 2005 to 2014 were identified from an institutional database. Asymptomatic anastomotic leakage was defined by CT performed systematically 4-8 weeks after rectal surgery, with no relevant clinical symptoms or laboratory examination findings during the postoperative course. RESULTS: Of a total of 428 patients, anastomotic leakage was observed in 120 (28·0 per cent) (50 asymptomatic, 70 symptomatic). After a mean follow-up of 40 months, local recurrence was observed in 36 patients (8·4 per cent). Multivariable Cox regression identified three independent risk factors for reduced local recurrence-free survival (LRFS): symptomatic anastomotic leakage (odds ratio (OR) 2·13, 95 per cent c.i. 1·29 to 3·50; P = 0·003), positive resection margin (R1) (OR 2·41, 1·40 to 4·16; P = 0·001) and pT3-4 category (OR 1·77, 1·08 to 2·90; P = 0·022). Patients with no risk factor for reduced LRFS had an estimated 5-year LRFS rate of 87·7(s.d. 3·2) per cent, whereas the rate dropped to 75·3(4·3) per cent with one risk factor, 67(7) per cent with two risk factors, and 14(13) per cent with three risk factors (P < 0·001). Asymptomatic anastomotic leakage was not significantly associated with LRFS in multivariable analysis. CONCLUSION: Symptomatic anastomotic leakage is a risk factor for disease recurrence in patients with rectal adenocarcinoma.

Small bowel obstruction in patients with a prior history of cancer: predictive findings of malignant origins.

BACKGROUND: Determining the cause of acute small bowel obstruction (SBO) in patients previously treated for cancer is necessary for adequate management, especially to avoid incorrectly classing the patient as palliative. We aimed to identify predictive factors for a malignant or a benign origin of SBO. METHODS: We retrospectively studied data for all patients with a prior history of cancer who had undergone operations for SBO between January 2002 and December 2011. Of the 124 patients included, 36 patients had a known cancer recurrence before surgery for SBO, whereas 88 had none. RESULTS: Causes of SBO were benign (post-operative adhesions, post-irradiation strictures) in 68 patients (54.8 %) and malignant in 56 (45.2 %). Incomplete obstruction, acute clinical onset, non-permanent abdominal pain, a shorter period between primary cancer surgery and the first episode of obstruction, and a known cancer recurrence were significant predictors of a malignant SBO. Benign causes of SBO were observed in 72.8 % of patients who had no known cancer recurrence, but were observed in only 11.1 % of patients whose recurrences were known. In patients with cancer recurrence-related SBO, post-operative mortality was 28.6 %, with a median overall survival of 120 days. 1 month after surgery, 38 (67.8 %) of these patients tolerated oral intake. CONCLUSION: A benign cause of SBO was observed in half of the patients with a prior history of cancer and in two-thirds of those without known recurrence. Even in the absence of bowel strangulation, surgery must be considered soon after failure of medical management to treat a possible adhesion-related SBO.

Long-term result of a pure tibiotalar dislocation in a child.

Pure ankle dislocation without fracture is a very rare injury in children. We report the case of a 9-year-old patient who sustained open medial dislocation of the tibiotalar joint without fracture. The management, contributive factors, and long-term results are reported with a review of the literature.