Evidence That Anorectal Transplantation Is the Logical Treatment for Serious Anorectal Dysfunction and Permanent Colostomy.

Anorectal dysfunction resulting in fecal incontinence or permanent colostomy is a current public health concern that strongly impairs patient quality of life. Present treatment options for this complex disease are expensive and usually ineffective. Anorectal transplantation is the logical treatment for fecal incontinence and permanent colostomy. This procedure has been clinically effective in a few cases reported in the medical literature. Furthermore, experiments in rats, pigs, and dogs have shown promising results, with functional recovery of the graft. In this article we describe the scientific evidence that anorectal transplantation may be an important option for treating anorectal dysfunction.

Functional outcome of autologous anorectal transplantation in an experimental model.

BACKGROUND: Although anorectal transplantation is a challenging procedure, it is a promising option for patients who have completely lost anorectal function or in whom it failed to develop, as in congenital malformations. The paucity of animal models with which to test functional outcomes was addressed in this study of anorectal manometry in rats. METHODS: Wistar rats were assigned randomly to four groups: orthotopic anorectal transplantation, heterotopic transplantation, sham operation, or normal control. Bodyweight and anal pressure were measured immediately before and after operation, and on postoperative days 7 and 14. ANOVA and Tukey's test were used to compare results for bodyweight, anal manometry and length of procedure. RESULTS: Immediately after the procedure, mean(s.d.) anal pressure in the orthotopic group (n = 13) dropped from 31·4(13·1) to 1·6(13·1) cmH2 O (P < 0·001 versus both sham operation (n = 13) and normal control (n = 15)), with partial recovery on postoperative day 7 (14·9(13·9) cmH2 O) (P = 0·009 versus normal control) and complete recovery on day 14 (23·7(12·2) cmH2 O). Heterotopic rats (n = 14) demonstrated partial functional recovery: mean(s.d.) anal pressure was 26·9(10·9) cmH2 O before operation and 8·6(6·8) cmH2 O on postoperative day 14 (P < 0·001 versus both sham and normal control). CONCLUSION: Orthotopic anorectal transplantation may result in better functional outcomes than heterotopic procedures. Surgical relevance Patients with a permanent colostomy have limited continence. Treatment options are available, but anorectal transplantation may offer hope. Some experimental studies have been conducted, but available data are currently insufficient to translate into a clinical option. This paper details functional outcomes in a rat model of anorectal autotransplantation. It represents a step in the translational research that may lead to restoration of anorectal function in patients who have lost or have failed to develop it.

Laparoscopic total mesorectal excision: early and late results.

BACKGROUND: Laparoscopic colectomy is superior to open colectomy in terms of short-term surgical outcomes. There is solid evidence indicating that laparoscopic and open surgery are equally effective for colon cancer, but for rectal cancer, the issues of neoadjuvant treatment, the need for total mesorectal excision and autonomic nerve preservation, and the technical demands of a well-constructed low colorectal or coloanal anastomosis challenge even the most specialized surgeons. This review discusses the available evidence on short-term and long-term outcomes after laparoscopic total mesorectal excision for rectal cancer. DATA SOURCES: Systematic MEDLINE and Embase searches of outcomes on laparoscopic total mesorectal excision were conducted and data were retrieved. CONCLUSIONS: Information on short-term and long-term outcomes after laparoscopic total mesorectal excision remains limited. Data are mainly retrospective and from randomized studies based on few cases that had minimal follow-up. Early non-oncologic surgical outcomes seem improved after laparoscopy, but an increased rate of positive circumferential resection margins has been detected. Though scarce, the available evidence on recurrence and survival does not indicates disadvantages to the laparoscopic approach.

Anorectal transplantation.

BACKGROUND: Anorectal transplantation is a valid procedure for the treatment of anorectal dysfunction; however, the lack of a suitable animal model has hampered the development of this method. We describe a simple technique for anorectal transplantation in the rat and compare this procedure with colostomy. METHODS: The anorectal segment including the skin surrounding the anus were freed by abdominal and perineal dissection. In a heterotopically transplanted group the segment was exteriorized by the formation of an anus through an abdominal incision. In an orthotopically transplanted group the segment was replaced in its original position and reimplanted by suturing. In another group a distal colostomy was performed. A sham-treated control group (simulated surgical procedure) was also included. Changes in behavior, characteristics of the stool, body weight and survival rate were assessed by daily clinical examination. Moribund animals, those with a weight loss of more than 30%, and those surviving at 1 month were killed by an overdose of anesthetic. The results were analyzed using the Mann Whitney, Student's t and chi-squared tests, and p<0.05 was considered significant. RESULTS: Within 4 days after the operation, animals submitted to orthotopic or heterotopic transplantation had achieved normal defecation, body weight gain and clinical evolution similar to the sham-treated group. The overall mortality in these groups was 4.16%. In contrast, colostomized animals showed a high incidence of diarrhea, intestinal obstruction, stress posture and violent behavior (p

Distribution of lymph nodes in the mesorectum: how deep is TME necessary?

BACKGROUND: Standardization of total mesorectal excision (TME) had a great impact on decreasing local recurrence rates for the treatment of rectal cancer. However, exact numbers and distribution of lymph nodes (LN) along the mesorectum remains controversial with some studies suggesting that few LNs are present in the distal third of the mesorectum. METHODS: Eighteen fresh cadavers without a history of rectal cancer were studied. The rectum was removed by TME and then was divided into right lateral, posterior and left lateral sides, which were further subdivided into 3 levels (upper, middle and lower). A pathologist determined the number and sizes of the LNs in each of the nine areas, b linded to their anatomical origin. RESULTS: Overall, the mesorectum had a mean of 5.7 LNs (SD=3.7) and on average each LN had a maximum diameter of 3.0 mm (SD=2.7). There was no association between the mean number or size of LNs with gender, BMI, or age. There was a significantly higher prevalence of LNs in the posterior location (2.8 per mesorectum) than in the two lateral locations (0.8 and 1.2 per mesorectum; p=0.02). The distribution of LNs in the three levels of the rectum was not significant. CONCLUSIONS: The distribution of LNs reinforces the fact that TME should always include the distal third of the mesorectum. Care must be taken to not violate the posterior aspect of the mesorectum.

Videolaparoscopic management of percutaneous liver biopsy complications.

Percutaneous liver biopsy is a routine procedure in the diagnosis, management, and follow-up of several liver disorders. Mortality and morbidity rates from percutaneous liver biopsy are low. This report of three cases of serious percutaneous liver biopsy complication and their management highlights the role played by videolaparoscopy as a diagnostic and therapeutic procedure in two different types of PLB complication: hemobilia and bile peritonitis. In two patients, intrahepatic arteriobiliary fistula developed with gastrointestinal hemorrhage (hemobilia). Both were treated with cholecystectomy and ligation of the right branch of the hepatic artery. In the third case, the percutaneous liver biopsy needle punctured the gallbladder, leading to bile peritonitis and acute abdomen, and the patient underwent videolaparoscopic cholecystectomy with aspiration and lavage of the abdominal cavity. Videolaparoscopic procedures are an adequate alternative for the management of serious percutaneous liver biopsy complications such as hemobilia and bile peritonitis. The advantages of a videolaparoscopy include low morbidity rates, quick recovery, good cosmetic result, and ability to resolve the complications of percutaneous liver biopsy.

Unintentional ileostomy: a complication of the videolaparoscopic method? Report of the first case.

Jejunostomy is widely acknowledged in the literature as a means for enteral nutrition. Complication rates range from 16% to 46% for the classical open technique and from 11% to 70% for the several mini-invasive techniques currently in use, including the laparoscopic techniques. The most probable complications are abscess, intestinal obstruction, abdominal wall infection, intraperitoneal leakage, enterocutaneous fistula, and loss, elbowing, or even rupture of the enteral probe. The authors report the case of a patient with severe malnutrition concomitant with advanced gastric cancer who underwent jejunostomy because of an incapacity for normal oral feeding. Previous attempts to pass a nasal enteral probe were not successful, even with the aid of endoscopy. Videolaparoscopy was indicated for adequate staging of the neoplasm and for performance of video-assisted jejunostomy. During the procedure, an extensive carcinomatous process was observed that rendered comprehension of the abdominal anatomy extremely difficult. Consequently, while attempting jejunal catheterization, unintentional catheterization of the terminal ileum took place. The authors discuss this first reported case of unintentional ileostomy and review the literature.