Intracorporeal or extracorporeal anastomosis after minimally invasive right colectomy: a systematic review and meta-analysis.

PURPOSE: As part of the wide adoption of minimally invasive surgery, intracorporeal anastomosis is becoming increasingly common. The benefits of minimally invasive versus open right colectomy are well known although the additional benefits of an intracorporeal anastomosis, performed laparoscopically or robotically, are unclear. The aim of this study was to assess the current literature comparing intracorporeal and extracorporeal anastomosis in the setting of laparoscopic and robotic-assisted right colectomy. METHODS: A systematic review and meta-analysis was conducted according to PRISMA and AMSTAR methods. Studies included were randomized controlled trials and prospective or retrospective cohort studies, between January 1 2010 and July 1 2021, comparing intracorporeal and extracorporeal anastomosis with laparoscopic and robotic approaches. Four groups were identified: laparoscopic extracorporeal anastomosis (L-ECA), laparoscopic intracorporeal anastomosis (L-ICA), robotic extracorporeal anastomosis (R-ECA), and robotic intracorporeal anastomosis (R-ICA). Operative time, rate of conversion to an open procedure, surgical site infection, reoperation within 30 days, postoperative complications within 30 days, and length of hospital stay were assessed. RESULTS: Twenty-one retrospective cohort studies were included in the final analysis. R-ICA and R-ECA had comparable operative times, but a robotic approach required more time than laparoscopic (68 min longer, p < 0.00001). Conversion to open surgery was 55% less likely in the R-ICA group vs. L-ICA, and up to 94% less likely in the R-ICA group in comparison to the R-ECA group. Length of hospital stay was shorter for R-ICA by a half day vs. R-ECA, and up to 1 day less vs. L-ECA. There were no differences in postoperative complications, reoperations, or surgical site infections, regardless of approach. However, the included studies all had high risks of bias due to confounding variables and patient selection. CONCLUSION: Robotic-assisted right colectomy with intracorporeal anastomosis was associated with shorter length of hospitalization and decreased rate of conversion to open surgery, compared to either laparoscopic or extracorporeal robotic approaches. Prospective studies are needed to better understand the true impact of robotic approach and intracorporeal anastomosis in right colectomy.

Ileal pouch fistulas after restorative proctocolectomy: management and outcomes.

BACKGROUND: Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm. METHODS: Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011. RESULTS: Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month-20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn's disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2-108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy. CONCLUSIONS: Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.

Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease.

AIM: Surgical repair of recto-vaginal fistula (RVF) in Crohn's disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. METHOD: A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. RESULTS: Fifty-one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. CONCLUSION: RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.

Visceral adhesions to hernia prostheses.

PURPOSE: To report our experience with abdominal adhesion formation to various synthetic and biologic prosthetic materials in a rat ventral hernia model. METHODS: A total of 14 prostheses, nine synthetic, four biologic, and one bioresorbable, were evaluated in the rat. Two synthetic prostheses had bioresorbable coatings and one consisted of synthetic and bioresorbable materials woven together. The model involved the removal from the midline of a 2.5 x 2.5-cm segment of full-thickness ventral abdominal wall with the test prosthetic material sewed into the defect, thus, exposing the viscera directly to one surface of the prosthesis. There were four or more rats in each group. Adhesions were assessed at autopsy 7 days after operation or later. The results were expressed as the percentage area of prosthesis surface involved. RESULTS: All 14 of the tested prosthetic materials induced adhesions. Vicryl Mesh and the four biologic varieties had lesser overall adhesion coverage than the bare synthetic prostheses. Sepramesh developed the least adhesion coverage (15%). The two synthetic materials with bioresorbable coatings had smaller areas involved compared to bare synthetic prostheses. CONCLUSIONS: All of the tested prostheses attracted adhesions. Biologic prostheses had smaller areas of coverage compared to synthetic prostheses. Barrier surfaces on synthetic meshes were associated with a much lesser extent of adhesion involvement.

Pharmacokinetics of linsidomine (SIN 1) after single and multiple intravenous short infusions in patients with renal insufficiency.

Pharmacokinetic measurements were performed in two groups of patients with coronary heart disease (CHD) after single and multiple dosing of 2 mg linsidomine (SIN 1). The drug was administered by intravenous short time infusion in 12 CHD-patients with renal insufficiency (RI group, Clcr: 11 +/- 6 ml/min) and in 12 CHD-patients with normal kidney function (control group, Clcr: 88 +/- 22 ml/min). The measurement of plasma concentration time courses of total SIN 1C (SIN 1 + SIN 1C) was found to be suitable for an estimation of the SIN 1C related half-life of the terminal phase (t50% = 1.5 +/- 0.5 h), as SIN 1 was eliminated from plasma rapidly (t50% = 12 to 20 min). Furthermore, the mean total SIN 1C plasma profiles were equal after single and multiple administration of the drug giving evidence that SIN 1C is not accumulating during repetitive dosing of SIN 1 in patients with renal disease. The mean maximum renal fraction of total SIN 1C excretion of RI-subjects (fe = 0.8 +/- 0.8% of dose) was significantly different from the corresponding mean value of the control group (fe(N) = 5.8 +/- 5.1% of dose). No differences were found for fe and fe(N) between day 1 and day 4. As SIN 1 is degraded in plasma very rapidly and as SIN 1C is cleared mainly extrarenally, any restrictions concerning repetitive SIN 1 dosage regimen should not be considered for CHD-patients with renal failure.

Regeneration of rhodopsin and bacteriorhodopsin. The role of retinal analogues as inhibitors.

The rate of regeneration of rhodopsin, from 11-cis-retinal and opsin, and bacteriorhodopsin from all-trans-retinal and bacterio-opsin, in the presence or absence of compounds whose structures partially resemble retinal were measured. Some of these compounds severely slowed down the regeneration process, but did not influence the extent of regeneration. In the case of compounds with a carbonyl functional group they were not joined to the active site of the apo-protein via a Schiff's base linkage since after treatment with NaBH4 an active apo-protein remained. The most effective inhibitors of rhodopsin regeneration were molecules whose structure could be superimposed on 9-cis or 11-cis retinal up to carbon atom 11. These C13 and C15 molecules were not distinguished between aldehyde, ketone or alcohol functional groups. The regeneration of bacteriorhodopsin was not inhibited by retinal analogues with short side chains. The most effective inhibitors were the all-trans C17-aldehyde (beta-ionylideneacetaldehyde) or C18-ketone (beta-ionylidenepent-3-ene-2-one) which, compared to retinal, lack two or three carbon atoms from the end of the poylene chain. The inhibition was very dependent upon the presence of the all-trans isomer and required aldehyde or ketone as functional group nitriles and alcohols were less effective. However, similarly to retinol, the all-trans C17 and C18 alcohols underwent a bathochromic shift and showed fine-structured spectra when mixed with bacterio-opsin.