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Crohn disease; Artificial intelligence; Three-dimensional imaging Enfermedad de Crohn; Inteligencia artificial; Imagen tridimensional Malaltia de Crohn; Intel·ligència artificial; Imatge tridimensional Aim The aim of this study is to demonstrate the added value of three-dimensional (3D) reconstruction models and artificial intelligence for preoperative planning in complex perianal Crohn's disease. MRI is the gold standard for diagnosis of complex perianal fistulas and abscess due to its high sensitivity, but it lacks high specificity values. This creates the need for better diagnostic models such as 3D image processing and reconstruction (3D-IPR) with artificial intelligence (AI) algorithms. Method This is a prospective study evaluating the utility of 3D reconstruction models from MRI in four patients with perineal Crohn's disease (pCD). Results Four pCD patients had 3D reconstruction models made from pelvic MRI. This provided a more visual representation of perianal disease and made possible location of the internal fistula orifice, seton placement in fistula tracts and abscess drainage. Conclusion Three-dimensional reconstruction in CD-associated complex perianal fistulas can facilitate disease interpretation, anatomy and surgical strategy, potentially improving preoperative planning as well as intraoperative assistance. This could probably result in better surgical outcomes to control perianal sepsis and reduce the number of surgical procedures required in these patients.

AIM Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

Background Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years. Objective The aim of this study is to perform an accurate anatomical study of the rectovaginal area in a cadaveric simulation model of total mesorectal excision to evaluate the possible structures and the dissection planes contained within the rectovaginal space. Design and setting This is a cadaveric study performed at the University of Valencia. Patients The pelvises of 25 formalin-preserved female cadavers were dissected. All the included specimens were sectioned in a midsagittal plane, at the level of the middle axis of the anal canal. Main outcome measures Careful and detailed dissection was performed to visualize the anatomical structures and potential dissection planes during anterior mesorectal dissection in cadavers. Histological sections were made of the posterior vaginal wall. Results The rectovaginal space contains loose areolar tissue that allows an easy dissection plane distally. A distinct and independent rectovaginal fascia or septum is not present. The existence of 3 layers fused together in the posterior vaginal wall can be identified more or less precisely because of their different coloration. The histological study confirms this macroscopic arrangement of the posterior vaginal wall in 3 layers: the mucosa, the muscular, and the adventitia. An independent rectovaginal septum can be generated only with a splitting of the adventitia. Limitations The cadaveric pelvic specimens of the oldest donors might have had age-related degeneration. Conclusions The present anatomical study has shown only a plane of loose areolar tissue between the rectal and vaginal wall. We can conclude that there is no independent fascia or septum in the rectovaginal space. See Video Abstract at http://links.lww.com/DCR/B456. ANATOMIA QUIRURGICA DEL ESPACIO RECTOVAGINAL: ?EXISTE UN TABIQUE RECTOVAGINAL INDEPENDIENTE O UNA FASCIA DE DENONVILLIERS EN LAS MUJERES: Debajo del reflejo peritoneal anterior, la pared rectal anterior y el mesorrecto estan separados de la pared vaginal posterior por un espacio rectovaginal virtual. En este espacio, la descripcion de un tabique rectovaginal independiente especifico como contraparte femenina de la fascia de Denonvilliers ha sido objeto de debate a lo largo de los anos.Realizar un estudio anatomico preciso del area rectovaginal en un modelo de simulacion cadaverica de escision mesorrectal total, con el fin de evaluar las posibles estructuras y los planos de diseccion contenidos en el espacio rectovaginal.estudio cadaverico realizado en la Universidad de Valencia.Se disecaron las pelvis de 25 cadaveres femeninos conservados en formalina. Todas las muestras incluidas fueron seccionadas en un plano medio sagital, a la altura del eje medio del canal anal.Se llevo a cabo una diseccion cuidadosa y detallada para visualizar las estructuras anatomicas y los posibles planos de diseccion durante la diseccion mesorrectal anterior en cadaveres. Se realizaron cortes histologicos de la pared vaginal posterior.El espacio rectovaginal contiene tejido areolar laxo que permite un plano de diseccion facil distalmente. No hay fascia o tabique rectovaginal distinto e independiente. La existencia de tres capas fusionadas en la pared vaginal posterior puede identificarse con mayor o menor precision debido a su diferente coloracion. El estudio histologico confirma esta disposicion macroscopica de la pared vaginal posterior en tres capas: la mucosa, la muscular y la adventicia. Un tabique rectovaginal independiente solo se puede generar con una division de la adventicia.Las muestras pelvicas de cadaveres de los donantes mas antiguos pueden haber tenido degeneracion relacionada con la edad.El estudio anatomico actual solo ha mostrado un plano de tejido areolar laxo entre la pared rectal y vaginal. Podemos concluir que no hay fascia o tabique independiente en el espacio rectovaginal. Consulte Video Resumen en http://links.lww.com/DCR/B456. (Traduccion-Dr. Adrian Ortega).

Background Strong agreement exists concerning the standards of pathologic reporting for total mesorectal excision and complete mesocolic excision. It represents a quality standard that correlates with survival. However, no agreed standards of reporting are available to define D3 lymphadenectomy for right colectomy. Objective The purpose of this study was to define anatomopathological standards of specimen quality obtained from the surgical specimen when an oncologic right hemicolectomy with D3 lymphadenectomy has been correctly performed. Design This study was conducted in 2 different phases. The first part consisted of a cadaver-based study of right colon anatomy, and the second part consisted of a prospective assessment of a series of surgical specimens obtained after right hemicolectomy for cancer. Settings The anatomic phase of the study was performed in collaboration with the University of Valencia Department of Anatomy and Embryology. The second part was performed at a colorectal unit of a tertiary hospital. Patients Seventeen cadavers were used for the first phase, and 65 surgical specimens were examined for the second part of the study. Main outcome measures In each specimen, the pathologists looked for anatomic structures defined as markers of quality standards of the D3 lymphadenectomy during the first phase. Specimens were classified as complete, partial, and incomplete D3 lymphadenectomy. Results Twenty percent of specimens were classified as incomplete D3 lymphadenectomy, 31% as partial, and 49% as complete. A median number of 14 (6-64), 22 (11-47), and 29 (14-55) lymph nodes were isolated (p = 0.01). Similarly, the median numbers of lymph nodes isolated in the area of D3 lymphadenectomy were 0 in incomplete, 1 (0-5) in Partial, and 3 (0-8) in Complete D3 lymphadenectomy specimens (p = 0.0001). Limitations A large multicenter study with adequate power is needed. Conclusions We propose the right mesocolic sail and trunk of superior right colic vein as new and reproducible anatomopathologic standards of D3 lymphadenectomy in oncologic right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/B149. PROPUESTA PARA NUEVOS ESTANDARES HISTOPATOLOGICOS EN LA LINFADENECTOMIA D3 EN EL CANCER DE COLON DERECHO: LA VELA MESOCOLICA Y LA VENA COLICA DERECHA SUPERIOR: Existe un claro acuerdo sobre los estandares de calidad patologicos para la escision total del mesorrecto y la escision completa del mesocolon. Son considerados "estandar de calidad" que se correlaciona con la supervivencia. Sin embargo, no se dispone de estandares de calidad para definir la linfadenectomia D3, en la colectomia derecha.Definir los estandares anatomopatologicos de calidad obtenidos de una muestra quirurgica, cuando se ha realizado correctamente una hemicolectomia derecha oncologica, con linfadenectomia D3.Dos fases diferentes. La primera parte consistio en un estudio basado en la anatomia del colon derecho, realizado en cadaveres, y la segunda parte consistio en una evaluacion prospectiva de una serie de muestras quirurgicas obtenidas despues de la hemicolectomia derecha para cancer.La fase anatomica del estudio se realizo en colaboracion con el Departamento de Anatomia y Embriologia de la Universidad de Valencia. La segunda parte se realizo en la Unidad Colorrectal de un hospital terciario.Se utilizaron diecisiete cadaveres para la primera fase y se examinaron 65 muestras quirurgicas para la segunda parte del estudio.En cada muestra, los patologos buscaron estructuras anatomicas definidas, como marcadores de los estandares de calidad de la linfadenectomia D3, durante la primera fase. Las muestras se clasificaron como linfadenectomia D3 completa, parcial e incompleta.El veinte por ciento de las muestras se clasificaron como "Linfadenectomia D3 Incompleta", el 31% como "Parcial" y el 49% como "Completa." Se aislo una media de 14 (6-64), 22 (11-47) y 29 (14-55) ganglios linfaticos respectivamente (p = 0,01). Del mismo modo, el numero medio de ganglios linfaticos aislados en el area de la linfadenectomia D3 fue 0 en "Incompleta", 1 (0-5) en "Parcial" y 3 (0-8) en muestras de "Linfadenectomia D3 Completa" (p = 0,0001).Se necesita un estudio multicentrico con potencia adecuada.Proponemos la vela mesocolica derecha y el tronco de la vena colica derecha superior, como estandares anatomopatologicos nuevos y reproducibles de linfadenectomia D3, en hemicolectomia derecha oncologica. Consulte Video Resumen en http://links.lww.com/DCR/B149.

Objective: Intra-abdominal septic complications (IASC) affect short-term outcomes after surgery for colon cancer. Blood transfusions have been associated with worse short-term results.The role of IASC and blood transfusions on long-term oncologic results is still debated. This study aims to assess the impact of these two variables on survival after curative colon cancer resection. Patients and methods: Retrospective analysis of a prospectively maintained database of patients who underwent curative surgery for colon cancer at a university hospital, between 1993 and 2010. Cox regression was used to identify the role of IASC and transfusions (alone and combined) on local recurrence (LR), disease-free survival (DES), and cancer-specific survival (CSS). Results: Out of the 1686 patients analyzed, 1277 fit in the inclusion criteria. Colorectal surgeons performed the procedure in 82.2% of the patients. Blood transfusions were administered to 25.8% of the patients. Thirty-day complication and mortality rates were 34.5% and 6.1%. IASC occurred in 9.9%. The mean follow-up was 66 months. The 5-year rates of LR, DES, and CSS were 7%, 79.8%, and 85.1%. The year of surgery and pT (Hazard ratio 9.35, 95% CI 1.23-70.9, for T4) and pN (Hazard ratio 2.57, 95% CI 1.39-4.72, for N2) stages were independent risk factors for LR. The same variables, bowel obstruction and surgeries performed by surgeons not specialized in colorectal surgery, were also associated with worse DES and CSS. IASC and blood transfusions were not associated with LR, DFS, and CSS, whether alone or combined. Conclusions: IASC and transfusions were not associated with worse oncological outcomes after curative colon cancer surgery per se. Other factors were more important predictors of survival. (C) 2019 Published by Elsevier Espana, S.L.U.

Introduction To explore the reported variability in the surgical management of ileocolonic Crohn’ s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn’s disease. Methods Anonymous videos demonstrating the small bowel walkthrough and anonymised patients’ clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas. Results Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel. Conclusions The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

BACKGROUND: TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN). OBJECTIVE: The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection. DESIGN: This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observational Studies in Epidemiology Statement. SETTINGS: The study was conducted in a specialized colorectal unit of a tertiary hospital. PATIENTS: A consecutive series of pT3-pT4a-pT4b patients with colon cancer who underwent curative surgery (1993-2010) were included, and patients with metastasis were excluded. MAIN OUTCOME MEASURES: A multivariate Cox regression analysis was performed to assess independent risk factors for 5-year local recurrence, peritoneal carcinomatosis-like recurrence, disease-free survival, and cancer-specific survival. RESULTS: A total of 1010 patients were analyzed (79.3% pT3, 9.9% pT4a, and 10.8% pT4b). At diagnosis, 22.0% had obstructive symptoms, and 10.5% had bowel perforation. A total of 72.2% of the surgeries were elective, and in 15.6% en bloc resection of contiguous organs was performed. Median follow-up was 62 months (38-100 mo). For the whole group, 5-year actuarial rates were 8.8% for local recurrence, 2.5% for peritoneal carcinomatosis, 75.5% for disease-free survival, and 81.8% for cancer-specific survival. At multivariate analysis, pT4a stage was an independent risk factor for local recurrence (p = 0.002; HR = 3.1), peritoneal carcinomatosis (p = 0.02; HR = 4.9), worse diseasefree survival (p = 0.002; HR = 1.9), and cancer-specific survival (p = 0.001; HR = 2.2). When considering only the 566 patients with >= 12 nodes identified, T stage was still associated with higher local recurrence (p = 0.04) and carcinomatosis rate (p = 0.04), as well as worse diseasefree (p = 0.009) and cancer-specific survival (p = 0.014). LIMITATIONS: This was a retrospective, single-center study. CONCLUSIONS: pT4a stage is an independent risk factor for worse oncologic outcome after curative colon cancer resection compared with pT3 and pT4b stages. The current pT4a-pT4b classification should be reconsidered. Of note, even in pT4a patients, 5-year carcinomatosis rate does not exceed 6%. See Video Abstract at http://links.lww.com/DCR/A926.

Objectives Perforated jejunal diverticulitis (PJD) is rare, but it has high mortality rates. The role of nonsurgical management is debated. The aim of this study is to assess the outcomes of medical and surgical management of PJD. Patients and methods A single-centre study on a series of emergency patients diagnosed with PJD between 2010 and 2016 was conducted. Results Eleven patients with PJD were treated (seven women). Nine out of 11 were diagnosed by a computed tomography scan, and two were diagnosed at laparotomy. The initial approach was medical treatment in five patients, based on clinical and imaging findings. Four (80%) of these five patients were discharged without the need for surgical intervention. The median hospital stay was 7.5 days. Seven patients required surgery overall with a median length of hospital stay of 10.8 days. Surgical procedures consisted of segmental bowel resection and primary anastomosis in six patients and simple closure in one. There was no perioperative deaths. One patient required percutaneous drainage because of anastomotic leak, and one required reoperation owing to evisceration. Discussion Selected patients with PJD can be successfully managed with conservative approach, based on clinical and computed tomography findings. Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.

BACKGROUND: Most perianal abscesses have a cryptoglandular origin, following the pathogenesis described by Parks in 1961. Supralevator abscesses have the most uncommon location. Nevertheless, such pathology results in a high morbidity because of their difficult diagnosis and treatment. OBJECTIVE: This study aimed to deepen the knowledge of the pathogenesis and management of supralevator abscesses, as well as the complications derived from incorrect treatment, by using simulation in cadavers. DESIGN: This study is an anatomosurgical description of pelvic and perianal zone and simulation of the different types of supralevator abscesses, their correct drainage routes, and secondary complex fistulas due to incorrect drainage. SETTINGS: This dynamic article is based on cadaveric simulation. PATIENTS: Three cadaveric pelvises (2 male and 1 female) were prepared in formalin and sagittally sectioned, and one perineal dissection was performed of a fresh male pelvis. This is an iconographic description of 3 patients treated for supralevator abscesses in our colorectal surgical unit. MAIN OUTCOME MEASURES: The virtual anatomical spaces map out a correct treatment. RESULTS: We reproduced the origin of the different types of supralevator abscesses, as well as their locations and possible drainage pathways, and we determined the definitive treatment of secondary fistulas and their morbidity due to their incorrect drainage. LIMITATIONS: The limitations of this study are inherent to anatomical studies without real case intervention. CONCLUSIONS: A proper anatomical knowledge of the supralevator abscesses and surgical training by using cadaveric simulations could improve the diagnostic criteria, facilitate the correct decision on surgical drainage pathways, and, thus, decrease postoperative morbidity in patients with this disease.

The superior right colic vein (SRCV) has been proposed as the main cause of superior mesenteric vein bleeding by avulsion during laparoscopic right hemicolectomy. Our objective is to identify the main vessel causing transverse mesocolic tension during the extraction of the surgical specimen or extracorporeal anastomosis and to perform an anatomical description of the SRCV. In this cadaveric study, we performed a simulation of right hemicolectomy and anatomical description of the surgical area of the gastrocolic trunk of Henle (SAGCTH), the gastrocolic trunk of Henle (GCTH), and SRCV. The length of the exteriorization of the anastomotic transverse colon (ATC) was measured before and after sectioning the vascular vessel causing the exteriorization tension. Five fresh cadavers and 12 formalin were dissected. In 100% of the specimens, the SRCV was present and drained in 95% into the GCTH and in 5% directly into the superior mesenteric vein (SMV). In 100% of the specimens, the SRCV caused the tension when extracting the ATC. The mean length of exteriorization of the ATC before and after SRCV section was 7.2 and 10.4 cm in formalin cadavers, meaning a 44% of increment in the length of exteriorization. In fresh cadavers, the mean length of exteriorization increased to 2.7 cm, meaning a 28% of the initial length of exteriorization. The SRCV is the main cause of tension in the extraction of the surgical specimen after right hemicolectomy. Its high tie increases the length of the ATC exteriorization, in about 3 cm, and could reduce the risk of SMV bleeding during laparoscopic right hemicolectomy and facilitate an extracorporeal anastomosis free of tension.

Background The medial approach in laparoscopic splenic flexure mobilization is based on the entrance to the lesser sac just above the ventral edge of the pancreas (VEOP). The artery of Moskowitz runs through the base of the mesocolon, just above the VEOP. The aim of this study was to assess the incidence of the artery of Moskowitz, its route and its distance from the VEOP. Methods We performed a cadaveric study on 27 human cadavers. The vascular arcades of the splenic flexure were dissected, the number of vascular arches, and the origin and localization of its terminal anastomosis were recorded. The splenic flexure avascular space (SFAS) was defined as the avascular zone in the mesocolon delimited by the VEOP, middle colic artery, ascending branch of the left colic artery and the vascular arch of the splenic flexure nearest to the VEOP and was quantified as the distance between the VEOP and the most proximal arch. Results The artery of Drummond was identified in 100% of the cadavers. In 5 of 27 (18%) Riolan's arch was present, and in 3 of 27 (11%) the Moskowitz artery was found. The mean distance from the VEOP to the artery of Moskowitz was 0.3 cm (SD 0.04). This vascular arch travelled from the origin of the middle colic artery to the distal third of the ascending branch of the left colic artery. The SFAS was greater (p = 0.001) in cadavers that only presented the artery of Drummond (mean 6.8 cm; SD 1.25) than in those with Riolan's arch (mean 4.5 cm; SD 0.5). Conclusions In the medial approach for laparoscopic mobilization of the splenic flexure, when only one of the arches is present, the avascular area is an extensive and secure territory. If the artery of Moskowitz is present, the area is nonexistent and this would contraindicate the approach due to risk of iatrogenic bleeding. A radiological preoperatory study could be essential for accurate and safe surgery in this area.

The aim of this study is to describe the diagnostic performance of magnetic resonance imaging in the management of supralevator abscess, regarding its origin, location, drainage route, subsequent treatment of the fistula, and long-term results. A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011 at a colorectal unit of a tertiary referral center. A magnetic resonance imaging was performed in all patients before surgical drainage, and its usefulness in assessing supralevator abscess origin was analyzed. Short- and long-term results after drainage were also evaluated. The final diagnosis of supralevator abscess and the location described in the magnetic resonance were confirmed intraoperatively in all patients. An ischiorectal origin was identified in nine patients, and perineal translevator drainage was performed placing a mushroom catheter through the ischiorectal or the postanal space. Four patients underwent secondary treatment of anal fistula: two rectal advancement flap and two non-cutting seton. In the other four patients, an intersphincteric origin was identified and transanal surgical drainage was performed placing a long-term mushroom catheter. Several weeks later, transanal unroofing of the residual cavity was performed and the fistula lay open to the anorectal lumen. In the long-term follow-up (median 61 months), only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis. Magnetic resonance imaging seems essential to clarify the location of supralevator abscess, its origin, and choice of the right drainage route. Subsequent treatment of the fistula is necessary to avoid recurrence.

Accuracy of MRI in assessing mesorectal fascia and predicting circumferential resection margin decreases in low anterior rectal tumors.The purpose of this work was to evaluate the accuracy of endorectal ultrasound in predicting the pathologic circumferential resection margin in low rectal anterior tumors and to compare it with MRI findings.This was a prospective series comparing the preoperative circumferential resection margin assessed by endorectal ultrasound and MRI with pathologic examination.The study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital.Between 2002 and 2008, 76 patients with mid to low rectal cancer were preoperatively evaluated by endorectal ultrasound and MRI and underwent total mesorectal excision without neoadjuvant radiochemotherapy. Twenty-seven patients with posterior or postero-lateral tumors were excluded, leaving 49 patients with anterior or antero-lateral tumors for the present subanalysis. We compared preoperative circumferential resection margin status using endorectal ultrasound and MRI with pathologic examination.We conducted a comparison between preoperative circumferential resection margin status and pathologic examination after total mesorectal excision surgery.Accuracy in predicting pathologic circumferential resection margin status was measured.Overall accuracy of endorectal ultrasound and MRI in assessing circumferential resection margin status was 83.7% and 91.8%, with negative predictive values of 97.2% and 97.5%. When focusing on low rectal tumors, the overall accuracy of endorectal ultrasound increased to 87.5%, whereas the accuracy of MRI decreased to 87.5%, with a negative predictive value of 95.6% for both diagnostic tests.The sample size is small, and interobserver variability in radiologic assessment was not evaluated.Endorectal ultrasound can help MRI in predicting circumferential resection margin involvement in mid to low anterior rectal cancer, especially at the low third of the rectum, with a high negative predictive value.

The root of the inferior mesenteric artery is an important area where autonomic nerves are close by, the dissection can be hard and laborious in order to avoid nerve damage; and the separation of mesocolon and retroperitoneum in this area can sometimes be difficult. The inferior mesenteric vein dissection is an alternative option as the first step during medial to lateral approach of laparoscopic left mesocolon mobilisation, as we have shown in this video based on two real cases and two anatomical cadaveric dissection. This article is protected by copyright. All rights reserved.

Aim Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery. Method All patients who underwent major colorectal abdominal surgery in our Colorectal Unit between 1996 and 2009 were analyzed. Data on nerve injury were prospectively collected. Results There were 2304 patients, of whom eight (0.3%) experienced intraoperative peripheral nerve injury. This occurred in 5/2211 (0.2%) open procedures and in 3/93 (3%) laparoscopic procedures. There was no association between intraoperative peripheral nerve injury and age, gender, body mass index, surgeon, operation time, American Society of Anesthesiology (ASA) score and urgent surgery. The use of Allen-type stirrups and a vacuum bag (in laparoscopic surgery) seemed to be protective for nerve injury in the lower and upper limbs respectively. Conclusion Adequate positioning and the use of pressure-free positioning devices may prevent intraoperative peripheral nerve injury, particularly during laparoscopy.

BACKGROUND: Although the National Quality Forum has endorsed the harvest of ≥12 lymph nodes as a standard quality indicator for colon cancer surgery, this minimum quantity is not reached in many centers. OBJECTIVE: The aim of this study was to assess the impact of the implementation of a mesocolon evaluation pathological protocol and ex vivo arterial methylene blue injection on the number of nodes harvested after colon cancer resection. DESIGN: A prospective series was compared with a historical group. SETTINGS: This study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital. PATIENTS: From June 2009 to December 2009, all the specimens after colon resection for cancer were analyzed with the use of a "mesocolon quality pathological evaluation" protocol. Moreover, a consecutive series of specimens was analyzed after arterial ex vivo injection of methylene blue. We compared the study groups with our previous series (2005-2009). INTERVENTIONS: The "mesocolon quality pathological evaluation" protocol was used with or without arterial methylene blue ex vivo injection. MAIN OUTCOME MEASURE: The primary outcome measure was the number of lymph nodes harvested. RESULTS: The mean number (SD) of lymph nodes collected was 20.6 (10.5), 37.1 (12.8), and 47.6 (12.9) (p < 0.0001) in the control, protocol, and methylene blue groups. In the control group, the minimum number of 12 and 18 lymph nodes collected was not reached in 92 (15.9%) and 258 (44.6%) patients. In contrast, all patients in the protocol and methylene blue groups had more than 18 lymph nodes collected. The multivariate analysis confirmed the application of the "mesocolon quality pathological evaluation" protocol and the methylene blue ex vivo injection, along with the type of resection and the length of the specimen, to be independent factors determining the number of nodes collected. LIMITATIONS: The patients are not randomly selected and are compared with a retrospective series. CONCLUSION: The implementation of a "mesocolon quality pathological evaluation" protocol along with the arterial ex vivo injection of methylene blue can significantly increase the number of nodes isolated after colonic resection, reaching a 100% rate of specimens with more than 12 nodes.

Aim This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin. Method A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler. Results Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence. Conclusion The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an alternative to decrease the risk of recurrence and incontinence.

Although the early diagnosis of anastomotic leak is a key point in reducing its clinical consequences, in daily practice, anastomotic leak diagnosis is often late.The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery.This is a prospective observational study.This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital.A series of 205 consecutive patients who underwent elective colorectal surgery in a specialized unit was prospectively analyzed. The following data were collected: demographic, surgical, ASA class, POSSUM, and morbidity. During the first 5 postoperative days, procalcitonin, C-reactive protein, leukocytes, platelets, and vital signs were evaluated daily.Daily assessment of clinical variable and serological data were conducted in the first 5 postoperative days.The primary outcome measure was the area under the curve at receiving operating characteristic curve analysis of the different variables in relation to the anastomotic leak.Anastomotic leak was detected in 17 (8.3%) patients; 11(5.4%) of the patients had a major anastomotic leak (need for drainage or reoperation). None of the variables evaluated were shown to be reliable in the early detection of anastomotic leak, considering both minor and major (maximum area under the curve0.80). In contrast, when considering only major anastomotic leaks, procalcitonin and C-reactive protein were reliable predictors on postoperative days 3 to 5 (p0.0001, area under the curve0.80). The best combination was procalcitonin at postoperative day 5 (area under the curve = 0.86), with a cutoff of 0.31 ng/mL, resulting in a 100% sensitivity, 72% specificity, 100% negative predictive value, and 17% positive predictive value.Only symptomatic patients were investigated to rule out anastomotic leakage.Procalcitonin and C-reactive protein are both reliable predictors of major anastomotic leak after colorectal resection, although procalcitonin is more accurate. Raised procalcitonin and C-reactive protein serum concentration on postoperative days 3 to 5 renders necessary a careful evaluation of the patient before discharge.