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Introduction: Limited financial resources require thoughtful expenditures even in socialised health care systems. Therefore a prospective randomized study was performed to evaluate the efficiency and cost effectiveness of hand sewn vs. stapled anastomoses in GI surgery. Material and Methods: All patients with elective GI surgery (except Crohn's disease or ulcerative colitis) were elegible to be enrolled in the study. Patients were randomly allocated to either group only if both ways of reconstruction were applicable after resection. Patients were especially followed for anastomotic insufficiencies or strictures, postoperative bleeding and motility. The cost was calculated considering not only the suture material used but also the cost for the staff involved to perform a certain anastmoses or operation. Results: A total of 324 anastomoses (170 stapled vs. 158 hand sewn) were performed during 200 operations in 200 Patients (80 female: 120 male) with a mean age of 60.2 (21-90) years. Of these operations 20.5% were gastrectomies, 14% gastric resections (BII), 15% Whipple's procedures, 4% segmental colonic resections, 18% right-sided -, 4% left-sided hemicolectomies, 22% sigmoidor anterior rectal resections and 2.5% total colectomies with pouch-anal anastomoses. Postoperative hospitalization was comparable in both groups. Postoperative motility (time to full oral diet, time with NG tube) was also comparable. Anastomotic insufficiencies were observed in 2.1% of all patients, 5 of those after stapled, 2 after hand sewn anastomoses. Hospital mortality was 1.5%, one patient died after insufficiency of her handsewn anastomoses, the others of diseases unrelated to the operative technique. All stapled reconstructions were performed significantly faster (p

Anastomotic breakdown, the most serious complication of restorative rectal resection, is responsible for half the postoperative morbidity rate and one-third of deaths1. While many surgeons defunction low anastomoses2, others consider this unnecessary3. A tube caecostomy can be used after on-table orthograde bowel lavage to avoid a stoma4. An obstructing unopened loop ‘colostomy’ offers potential advantages5. It can be returned to the abdomen if the anastomosis heals soundly or opened into a colostomy if it leaks. This method was evaluated in seven patients.

Zur Prufung der Kontinenz nach Rectumresektion mit peranaler Anastomosierung wurde bei 17 Patienten eine Befragung nach Kelly und eine Manometrie des Anorectums durchgefuhrt. Festgestellt wurde eine verminderte Compliance, ein erniedrigter analer Ruhedruck und eine abgeschwachte Relaxation des Sphincter internus nach Rectumdistension. Die Beurteilung der Kontinenz ergab in 10 Fallen eine normale und in 4 Fallen eine ausreichende Kontinenz.

Fifteen patients with ulcerative colitis and 11 patients with ulcerative proctitis have been observed and studied for periods ranging from one to 15 years. It is suggested that the clinical course of the two disorders is quite distinct. Further, while the serum immunoglobulins were within normal limits in ulcerative proctitis, significant increases in the serum alpha(2)-, beta-, and gamma-globulins and in the IgA and IgG concentrations were found in ulcerative colitis. Despite total colectomy for ulcerative colitis, the serum IgG and IgA concentration remained high and even after subsequent rectal resection the relative IgA concentration continued to increase. The significance of these findings is discussed.

Sixty-two cases of anorectal syndrome of lymphogranuloma have been observed. A few conclusions seem justified. 1. 1. The anorectal syndrome of lymphogranuloma is probably a specific entity. 2. 2. The clinical picture possesses adequate character to enable a presumptive diagnosis. 3. 3. The diagnosis is confirmed by the Frei test, and tumor must be eliminated by biopsy. 4. 4. Pharmaceutical and antigen therapy are of no striking value in the treatment of the stricture. 5. 5. Surgical treatment should be conservative. Dilatations should be conducted gently. Where colostomies are done, their closure should not be anticipated. Radical rectal resection may be justified in the occasional case. 6. 6. Syphilis, gonorrhea and chancroids are probably rare as causative agents in rectal stricture.

Highlights • Colovaginal anastomosis is a surgical error that should not happen. • It could be avoided by a proper intraoperative technique. • The main reason why it is still occurring is an unacceptable lack of knowledge of some surgeons. • There are no excuses for such surgical errors. • In our case, additional unacceptable errors were made during the postoperative follow-up., Introduction The low anterior rectal resection and double stapling technique are well-established surgical procedures with well-known pitfalls, potential complications, and preventive measures. Colovaginal anastomosis is a surgical error which should not occur. Presentation of case A 39-year old woman underwent low anterior resection with double stapling technique, for rectal carcinoma in the City Hospital. On the fifth postoperative day she noticed passage of gas and two days later passage of feces from vagina. The surgeons who performed the operation explained to her that it is a normal condition for such modern procedure that is supervised by international educator engaged by the Government. The patient lived with this condition, passage of gas and feces from the vagina and nothing from anus for three months when her oncologist referred her for a second opinion at the University Clinic for Digestive Surgery. The digital examinations revealed a blind rectal stump, and feces in vagina; thus having the patient’s history in mind, we assumed that the patient had a colovaginal anastomosis. Our assumption was confirmed by two succeeding radiological examinations. Initially, water soluble contrast enema was performed to assess the colon, when a clear-cut blind rectal stump was detected. Afterwards, the vaginography revealed a copious flow of contrast material from the vagina toward the sigmoid colon. After a few days, a restorative surgery was done. Discussion Most of the early postoperative complications are a result of surgical errors. Conclusion We believe that there is no excuse for such a surgical error and postoperative follow-up.

Introduction Different results have been reported about postoperative outcomes of conversion during laparoscopic colorectal surgery. We aimed to detect the effect of conversion on postoperative outcome and to identify features associated to better outcome after conversion. Methods Two hundred-fourteen mini-invasive left colonic and rectal resections were retrospectively analysed. Two groups were identified: mini-invasive colorectal surgery (MI) that includes both laparoscopic and robotic resections, and conversion to open surgery. Results Among 214 colorectal procedures, 189 were MI. Conversion rate was 11.7%. Operating time was shorter for MI at overall analysis ( p 0.003) and sub-analysis of left colectomies ( p 0.001). MI procedures had shorter hospital stay ( p 0.000) both in left colectomy and rectal resection ( p 0.008 and p 0.001 respectively). A shorter time to first flatus emission was detected in MI group in both overall analysis ( p 0.003) and procedure's sub-analysis (left colectomy p 0.032; anterior rectal resection p 0.040). Oral feeding was resumed earlier after mini-invasive rectal resections ( p 0.014). Converted procedures required more blood transfusions ( p 0.000) and grade II complication rate was lower after MI procedures ( p 0.013). Conversion presented higher anastomotic leakage and reoperation rates ( p 0.035 and p 0.006 respectively). Conversion before 105 min (early conversion) had a significant lower number of blood transfusions ( p 0.047). Conclusions Conversion is associated to higher rate of blood transfusions, grade II complication and slower recovery. Earlier conversion has better outcomes. Colorectal surgeons should identify any critical aspects that could avoid late conversion allowing reducing negative effects of conversion.

Fifteen patients with urinary retention following rectal resection were examined urodynamically, including cystometry and simultaneous measurement of flow and pressure in the bladder and in the abdomen. Five patients suffered from bladder neck obstruction. This was in most cases put down to a preexisting prostatic enlargement. In 4 patients it was impossible to detect any function of the bladder muscle. Detrusor insufficiency was the cause of retention in the remaining 6 patients.

Two hundred and twenty consecutive, unselected cases of restorative rectal resection are reported. The operative mortality was 8.3 per cent; 3.5 per cent in patients less than 70 years old and 13 per cent over that age. Leakage at the colorectal suture line was an intractable problem, uninfluenced by anastomotic technique, but the introduction of antimicrobial prophylaxis as a routine was followed by a statistically significant reduction in the leak rate. Postoperative rectal function was satisfactory but temporary stenosis at the suture line was not uncommon. In only one case was it permanent, requiring regular dilatation. Recurrence of malignant disease occurred in 50 per cent of cases followed for at least 2 years; 35 per cent general disease, 15 per cent localized to the pelvis. These figures do not differ significantly from those following total rectal excision, which is now necessary in only 1 in 10 cases where the growth lies within 10 cm of the anus.

The efficacy of constructing an ileal pouch in association with an ileoanal anastomosis after mucosal proctectomy has been well established. Ordinarily, the pouch is fashioned at the time of mucosal proctectomy. This report describes a patient whose end ileostomy was successfully converted to a J-pouch 24 years after intersphincteric resection of his rectum for ulcerative colitis. Postoperative anal manometric data are presented, and the potential for applying this operation to other patients who have had previous intersphincteric rectal resections is discussed.

Problems of sexual dysfunction were surveyed by questionnaire mailed to women who had undergone rectal resection and ostomy surgery over a ten-year period. Completed questionnaires were returned by 30 respondents, 19 to 54 years of age, who indicated both physical and psychological problems. Many of the problems were solved by the patients themselves, but the way can be made easier with the help of an understanding surgeon and knowledgeable stoma therapist who can create a climate in which the patient may feel at ease asking for guidance concerning sexual matters.

The techniques of restoring intestinal continuity after rectal resection for cancer have evolved throughout this century. For the most part, circular staplers have displaced the other pioneering and innovative techniques that our mentors and predecessors devised to improve the quality of life for our patients. With new technology, so also emerge new problems. Although the future likely will render many of our present techniques obsolete, for example, with refining of tissue adhesives, it is incumbent on us to recognize the limits of our present array of weapons and the limits placed on us by the biology of the tumor. About the latter, this means maintaining intellectual honesty in conducting a good cancer operation; about the former, we have to recognize that most of the pitfalls of stapling are preventable or correctable.

We randomly allocated 100 patients undergoing colonic or rectal resections to have their anastomoses made either by a single layer of braided polyester interrupted sutures, or by the SPTU circular stapling instrument. Twelve anastomoses leaked, 4 being detected only by contrast enema. There was no difference in leak rate between the two anastomotic methods, but patients in the stapled group had a significantly higher incidence of minor wound infection, and spent significantly more days in hospital after operation. The stapling instrument is no safer than sutures for colonic and rectal anastomoses, but considerably facilitates the performance of a low anterior resection.

A self washout method was performed by ten patients who had defecational complaints following an anterior resection. A commercially available colostomy washout set was used for this procedure. When the patient sat down, the cone tip of the set was pressed into the anal canal by pushing the cone with the palm of the hand. The volume of water for irrigation used was 500 to 1000 ml and the subsequent defecation time was from 20 to 50 minutes. In all cases, the frequent urge to defecate disappeared and after normal defecational function had been recovered, the self washout was able to be discontinued.

Summary A technique is described for construction of the colorectal or colo-anal anastomosis in low rectal resection by using an automatic circular stapling device and inserting the anorectal purse-string suture peranally from below. This method was employed in 4 patients resulting in complete healing in 3 cases and a moderate leak in 1, which, however, eventually healed satisfactorily.

This article presents numerous illustrations that show a variety of techniques for the restoration of intestinal continuity after low anterior resection. The conclusion is that, at extremely low levels, the EEA stapler anastomosis can be securely performed at levels at which manual anastomosis would not be possible.

Twenty patients underwent a supra levator total pelvic exenteration with low rectal anastomosis for recurrent or persistent cervical carcinoma following radiotherapy. Fourteen (70%) had complete healing. Five of 9 patients with protective colostomies had complete healing while 9 of 11 without protective colostomies healed. Three of 7 patients with a rectal stump length of less than 6 cm healed while 11 of 13 whose rectal stump was 6 cm or greater experienced complete healing. Overall, 13 of the 20 patients are clinically free of disease and 8 (61%) of those enjoy life with excellent bowel continence. A low rectal anastomosis should be attempted in those patients undergoing a supralevator total pelvic exenteration.

Experiences with 565 colonoscopic polypectomies and 91 colonic and rectal resections containing infiltrating carcinoma in polyps are reviewed. A plan of management based on pathologic study of resected polyps is formulated to avoid further unnecessary surgery. It was concluded that: (1) Tubular adenomas containing invasive carcinomas have a low incidence of metastatic node involvement. This incidence is related to the depth of carcinomatous involvement. Resection of these polyps with a margin free of carcinoma constitutes definitive and adequate treatment and that (2) Villous adenomas containing invasive carcinoma have a high incidence of metastatic nodal involvement, and operative resection of the involved area of the colon is recommended, and that (3) Pedunculated tubulovillous adenomas containing invasive carcinoma behave like tubular adenomas, and the recommendations for further surgery in the patient with tubular adenomas with carcinoma apply equally well for these lesions. Sessile tubulovillous polyps tend to behave like villous adenomas, and if invasive carcinoma is demonstrated, further operation is recommended.

A technic of rectal resection for benign diseases has been described, in which the cleavage plane between the rectal submucosa and muscularis is used. Dissection within the muscularis without mobilization or eversion of the rectum protects pararectal viscera. Pelvic peritoneal closure is facilitated and sexual function in the male is not impaired. This operative technic has been used successfully in two male patients. These encouraging results suggest further clinical trial when proctectomy for benign disease is indicated.

One of the most important steps in the procedures of the surgeon on opening the abdomen of a patient with cancer is to inspect the liver with care, in order to determine possibly the presence or absence of metastatic cancer. The determination is one which may change completely the nature and degree of the contemplated operation. For example, some surgeons rigidly refuse to proceed with a gastrectomy, pancreatectomy, or rectal resection in the presence of hepatic metastases, regardless of their small size or small number, whereas other surgeons with different points of view would proceed with the resection and, even under favorable circumstances, practice metastasectomy. Moreover, an operation applied for obvious palliation is often of more limited scope than the radical procedures designed with hope for cure. We thought it to be of interest to determine the accuracy of our diagnosis of freedom or noninvolvement of the liver by metastatic

Nineteen patients who had a suture-line recurrence of a bowel neoplasm are reviewed. This sequela to colonic or rectal resection and anastomosis is most common distally, and following segmental or anterior resections. It was absent after small-to-large bowel anastomosis, and following pull-through resection. Three types of suture-line recurrence were observed at exploration, and the times of development fell into early and late groups. Prognosis was best where there was mucosal recurrence only and when this developed late.

In the surgical treatment of cancer, it would seem that the limit has been reached in the extent of the body that can be dispensed with, with the continued maintenance of life. At times there has seemed to be more or less competition among surgeons as to how much of the human body could be removed surgically and leave a remnant compatible with living. The surgeon has to weigh these procedures carefully in the case of the individual patient. He must decide as to the prospect of palliative relief or the more remote possibility of cure. He should estimate the probable degree of relief in relation to the resultant disability; the temperamental make-up of the individuals concerned; their social and business obligations; and the risk of operative mortality. All these factors should enter into consideration when the surgeon is making his decision. He must take care that in deciding not to accept the risk of a major operative procedure he is not acting unjustly in deciding that the patient’s cancer is too far advanced and the risk too great. He must not be influenced by his own fear of criticism from colleagues or the lay public. The surgeon faced with the challenge of an advanced cancer must be able to put himself in his patient’s place. Very few surgeons ever close the chest or abdomen after a decision that they will not remove a certain cancer without experiencing a painful feeling of futility.

We have studied the resorption of 131INa from the rectum on a group of patients with different diseases of the rectocolon and on normal individuals. We were led by the assumption that measurements of rectally administered isotopes, effected in time at the level of the liver, would give us information concerning the absorption of these substances from the rectum.

Aim The efficacy of sacral nerve stimulation (SNS) in low anterior resection syndrome (LARS) is largely undocumented. A review of the literature was carried out to study this question. Method Pubmed, Medline and Cochrane databases were searched for relevant articles up to August 2014. Studies were included if they evaluated the use of SNS following rectal resection and assessed at least one of the following end-points: bowel function, quality of life and ano-neorectal physiology. No restrictions on language or study size were made. Results Seven papers were identified including one case report and six prospective case series. These included 43 patients with a median follow-up of 15 months. After peripheral nerve evaluation definitive implantation was carried out in 34 (79.1%) patients. Overall, 32 (94.1%) of the 34 patients experienced improvement of symptoms which, based on intention to treat, was 32/43 (74.4%). Conclusion The review suggests that SNS for faecal incontinence in LARS has success rates comparable to its use for other forms of faecal incontinence.

Between 1982 and 1991, we performed conservative operations on 11 women aged 23 to 39 years (mean 28 years) with extensive rectovaginal septum endometriosis. Before the intervention, severe deep dyspareunia was reported by 6 patients and moderate by 4, severe dysmenorrhea by 4 and moderate by 5, and severe acyclic pelvic pain by 2, moderate by 4, and mild by 1. The subjects underwent vaginoabdominal surgery with subtotal removal of the posterior vaginal fornix and excision of intraperitoneal endometriosis, with presacral neurectomy in 7 cases and low anterior rectal resection in 5. After a mean follow-up of 41 months, 6 women have no dyspareunia and 5 have mild discomfort, 4 have no dysmenorrhea, 3 have moderate and 4 mild menstrual pain, and 6 have mild acyclic disturbances. Three of nine infertile patients conceived. In selected young women wanting children, with pelvic pain symptoms unrelieved by medical treatment, a conservative vaginoabdominal surgical approach is feasible, and satisfactory ...

Background A temporary ileostomy may reduce symptoms from anastomotic leakage after rectal cancer resection. Earlier results of the EASY trial showed that early closure of the temporary ileostomy was associated with significantly fewer postoperative complications. The aim of the present study was to compare health-related quality of life (HRQOL) following early versus late closure of a temporary ileostomy. Methods Early closure of a temporary ileostomy (at 8–13 days) was compared with late closure (at more than 12 weeks) in a multicentre RCT (EASY) that included patients who underwent rectal resection for cancer. Inclusion of participants was made after index surgery. Exclusion criteria were signs of anastomotic leakage, diabetes mellitus, steroid treatment, and signs of postoperative complications at clinical evaluation 1–4 days after rectal resection. HRQOL was evaluated at 3, 6 and 12 months after resection using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29 and Short Form 36 (SF-36®). Results There were 112 patients available for analysis. Response rates of the questionnaires were 82–95 per cent, except for EORTC QLQ-C30 at 12 months, to which only 54–55 per cent of the patients responded owing to an error in questionnaire distribution. There were no clinically significant differences in any questionnaire scores between the groups at 3, 6 or 12 months. Conclusion Although the randomized study found that early closure of the temporary ileostomy was associated with significantly fewer complications, this clinical advantage had no effect on the patients' HRQOL. Registration number: NCT01287637 (https://www.clinicaltrials.gov).

Background Low anterior resection syndrome (LARS) is a frequent problem after rectal resection. Transanal irrigation (TAI) has been suggested as an effective treatment in patients who have developed LARS. This prospective RCT was undertaken to evaluate the effect of TAI as a prophylactic treatment to prevent symptoms of LARS. Methods Patients who had undergone ultralow rectal resection were randomized to start TAI on a daily basis, or to serve as a control with supportive therapy only after ileostomy closure. All patients were seen after 1 week, 1 month and 3 months, and the maximum number of defaecation episodes per day and night documented during follow-up. Wexner score, LARS score and Short Form 36 questionnaire responses were evaluated in both groups. Results Thirty-seven patients could be evaluated according to protocol (TAI 18, control 19). The maximum number of stool episodes per day and per night was significantly lower among patients who underwent TAI at 1 month (median 3 versus 7 episodes/day in TAI versus control group, P = 0·003; 0 versus 3 episodes/night, P = 0·001) and 3 months (3 versus 5 episodes per day, P = 0·006; 0 versus 1 episodes/night, P = 0·002). LARS scores were significantly better in the TAI group after 1 month (median 16 versus 32 in control group; P = 0·044) and 3 months (9 versus 31; P = 0·001). A significantly better result in terms of Wexner score was seen in the TAI group after 3 months (median 2 versus 6 in controls; P = 0·046). Conclusion Prophylactic TAI led to a significantly better functional outcome compared with supportive therapy for up to 3 months. Registration number: DRKS00011752 ( http://apps.who.int/trialsearch/).

Three patients who had a prostatic urethral fistula into the presacral space and perineal urinary drainage after rectal resection or vascular injury with rectal sloughing were treated successfully by a transperineal, extraurethral scrotal inlay flap.