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We investigate the enhanced terahertz generation in the organic crystal BNA when pumped by compressed high-energy ytterbium laser pulses. By compressing the pump pulses from 170 fs down to 43 fs using an argon-filled hollow-core fiber and chirped mirrors, the terahertz conversion efficiency is increased by 2.4 times, leading to the generation of multi-microjoule terahertz pulses with a frequency spectrum almost twice as wide, extending up to 19 THz. These findings showcase a simple and efficient way to generate intense and broadband terahertz pulses by means of an amplified ytterbium laser system.

Purpose of Review: Despite growing evidence supporting the diagnostic utility of coronary computed tomographic angiography (CCTA) for anatomical assessment of coronary artery disease (CAD), its is underutilized in peri-procedural planning especially in the acute setting., Recent Findings: Incorporation of flow reserve measurement techniques into CCTA has expanded its sensitivity and specificity for obstructive disease, and continued improvement in CCTA technology permits more accurate cross-sectional plaque characterization. CCTA has the potential to constitute the mainstay of pre-procedural planning for patients with CAD, who are being considered for percutaneous coronary intervention , reducing their ad hoc nature while facilitating equipment selection and improving catheterization lab safety and throughput. Future studies are needed to compare the cost and benefits of more frequent use of routine pre-procedural CCTA prior to coronary angiography and intervention., Competing Interests: Declarations. Human and Animal Rights and Informed Consent: This article does not contain any studies with human or animal subjects performed by any of the authors. Competing Interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose of the Review: Contrast-associated acute kidney injury (CA-AKI) remains a significant concern in diagnostic and invasive procedures, particularly in the context of iodinated contrast material administration. The traditional definition of CA-AKI, based on serum creatinine elevation following contrast exposure, may not accurately capture its multifactorial nature., Recent Findings: Studies have provided new insights into the differential incidence of CA-AKI between intravenous and intraarterial contrast administration, emphasizing the importance of tailored preventative strategies for high-risk procedures. This higher risk may arise from two proposed mechanisms: one implicating free radical formation leading to cytotoxicity and apoptosis in renal cells and another suggesting that contrast media alter renal hemodynamics, particularly in the outer medulla, by constricting the vasa recta and reducing medullary flow. Advances in technology and patient care, including contemporary use of low-osmolar contrast agents and hydration protocols, mitigate CA-AKI risk. Diagnostic and invasive procedures should not be avoided solely due to concerns about renal dysfunction if the patient is likely to benefit clinically., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: With the increase in popularity of cannabis and its use and the lack of large-scale data on cannabis use and venous thromboembolism and pulmonary embolism (PE), we used a nationally representative cohort of young adults (aged 18-44 years) to compare the odds of admissions and in-hospital mortality of PE with and without cannabis use disorder (CUD)., Methods and Results: Identified patients with PE using the National Inpatient Sample (2018) were compared for baseline, comorbidities, and outcomes. Multivariable regression analysis, adjusted for covariates, was used to compare the odds of PE in young patients with CUD (CUD+) versus those without (CUD-) and those with prior venous thromboembolism. Propensity score-matched analysis (1:6) was also performed to assess in-hospital outcomes. A total of 61 965 (0.7%) of 8 438 858 young adult admissions in 2018 were PE related, of which 1705 (0.6%) had CUD+. On both unadjusted (odds ratio, 0.80 [95% CI, 0.71-0.90]; P <0.001) and adjusted regression analyses, the CUD+ cohort had a lower risk of PE admission. The CUD+ cohort had fewer routine discharges (58.3% versus 68.3%) and higher transfers to short-term (7.9% versus 4.8%) and nursing/intermediate care (12.6% versus 9.5%) ( P <0.001). The PE-CUD+ cohort of in-hospital mortality did not differ from the CUD- cohort. Propensity score-matched (1:6) analysis revealed comparable mortality odds with higher median hospital stay and cost in the CUD+ cohort., Conclusions: Young adults with CUD demonstrated lower odds of PE hospitalizations without any association with subsequent in-hospital mortality. The median hospital stay of the CUD+ cohort was longer, they were often transferred to other facilities, and they had a higher cost.

Introduction: Transcatheter aortic valve implantation (TAVI) plays a vital role in patients with symptomatic aortic stenosis. Despite the mortality benefit of TAVI, embolic stroke remains a feared complication. As a result, transcatheter cerebral embolic protection (TCEP) devices have been developed to reduce this risk. Given the ongoing debate of TCEP in TAVI, we performed a systematic review and meta-analysis of all randomized controlled trials to date to identify outcomes of periprocedural stroke using the Sentinel™ cerebral protection system (CPS)., Methods: MEDLINE, Cochrane, and Scopus databases were utilized from inception until 12/2023. PRISMA criteria was utilized. Keywords included "cerebral embolic protection", "sentinel cerebral protection system", "transcatheter aortic valve implantation", and "transcatheter aortic valve replacement". Primary outcome was periprocedural stroke. Secondary outcomes included periprocedural disabling and non-disabling stroke, all-cause mortality, transient ischemic attack, delirium, acute kidney injury, vascular complications, bleeding, and pacemaker implantation. Risk ratios (RR) were measured via Mantel-Haenszel method with fixed analysis. Heterogeneity was assessed via chi-squared and Higgin's I 2 test., Results: Four trials with 3528 patients were assessed. SAPIEN 3 was the most common bioprosthetic valve used. The average age was 79.4 years with 41.9% of the sample size being females. The most prevalent comorbidities were hypertension, diabetes mellitus, and coronary artery disease. There was no difference in periprocedural stroke in patients who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.75, P = 0.12). Periprocedural disabling strokes were less likely in those who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.41, P = 0.02) with a number needed to treat (NNT) of 123. All other outcomes did not reach statistical significance., Conclusions: In our analysis, there was no difference between TAVI with the Sentinel™ CPS compared to TAVI without TCEP in regard to risk of periprocedural stroke; however, it was associated with a decreased risk of periprocedural disabling stroke., (© 2024. The Author(s).)

Purpose of Review: There is ample evidence of the benefits and safety of low-density lipoprotein (LDL)-lowering therapies in the prevention of atherosclerotic cardiovascular disease. While statins remain the first-line agent for LDL reduction, several new therapies are now available. This narrative review provides an overview of currently available non-statin LDL-lowering agents, specifically mechanisms of action and data on efficacy and safety. It also discusses recommendations on their use in clinical practice., Recent Findings: Ezetimibe, PCSK9 inhibitors, and bempedoic acid have proven safe and efficacious in reducing cardiovascular events in large randomized controlled trials. Inclisiran is a promising agent that suppresses PCSK9 mRNA translation and is currently under investigation in a large clinical outcomes randomized controlled trial assessing its effect on clinical outcomes. Expert consensus advocates for lower LDL targets in higher risk patients and escalation to or a combination of non-statin therapies as needed to achieve these goals., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice., Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure., Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management., Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training., Trial Registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020., (© 2024. The Author(s).)

The goal of this investigation is to evaluate the accuracy of handheld ultrasound score in assessing right atrial (RA) pressure in patients with obesity with heart failure. We prospectively studied 123 patients with heart failure referred for right-sided cardiac catheterization. Handheld ultrasound was performed before catheterization to evaluate volume status by estimating RA pressure using end-expiratory inferior vena cava (IVC) dimension, IVC respiratory collapsibility, and right internal jugular (RIJ) vein respiratory collapsibility. A 3-point simple score was created using multiple logistic regression. The patients were divided into 2 groups based on body mass index. The performance of this score was assessed using the receiver operating characteristics curve in each subgroup and was compared with the performance of the 2-point score (expiratory IVC dimension, IVC respiratory collapsibility). Median age was 58 years (interquartile range 48 to 65), and 37% were women. The 3-point score including RIJ performed better than did the 2-point score in patients with obesity (area under the curve 0.84 [0.74 to 0.95] vs 0.69 [0.58 to 0.81], p = 0.001). The performance of the scores did not differ in patients without obesity (area under the curve 0.85 [0.74 to 0.95] vs 0.82 [0.71 to 0.93], p = 0.49). In patients with obesity, the 3-point score had a specificity of 100% and sensitivity of 21% (11% to 31%) for elevated RA pressure ≥10 mm Hg. In conclusion, a 3-point score including both RIJ and IVC assessment performed better in patients with obesity with heart failure and highlights the importance of comprehensive evaluation in patients with obesity to achieve an accurate, noninvasive assessment of volume status., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aim: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology., Methods: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG., Results: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations., Conclusion: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise., (© 2023 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results., (© 2023. Italian Society of Surgery (SIC).)

As high-average power ultrafast lasers become increasingly available for nonlinear conversion, the temperature dependence of the material properties of nonlinear crystals becomes increasingly relevant. Here, we present temperature-dependent THz complex refractive index measurements of the organic crystal BNA over a wide range of temperatures from 300 K down to 80 K for THz frequencies up to 4 THz for the first time. Our measurements show that whereas the temperature-dependent refractive index has only minor deviation from room temperature values, the temperature-dependent absorption coefficient decreases at low temperature (-24% from 300 K to 80 K). We additionally compare these measurements with conversion efficiency and spectra observed during THz generation experiments using the same crystal actively cooled in the same temperature range, using an ultrafast Yb-laser for excitation. Surprisingly, the damage threshold of the material does not improve significantly upon active cooling, pointing to a nonlinear absorption mechanism being responsible for damage. However, we observe a significant increase in THz yield (+23%) at lower temperatures, which is most likely due to the reduced THz absorption. These first findings will be useful for future designs of high-average power pumped organic-crystal based THz-TDS systems.

Depression and coronary artery disease are leading causes of mortality in adults in high-income countries. Due to the paucity of data on the young, we aimed to investigate the prevalence of cardiovascular disease (CVD) risk factors and associated major adverse cardiac and cerebrovascular events (MACCE) in young adults hospitalized with comorbid depression a decade apart. We conducted a retrospective analysis of the National Inpatient Sample Database for the years 2007 and 2017. Young adults (18-44 years) hospitalized with comorbid depression were identified using ICD-9 CM/ICD-10 codes. Frequency and trends in demographics, comorbidities including CVD risk factors, and MACCE have been compared between the 2017 vs 2007 cohorts. A total of 1,274,118 admissions with a median age of 34 years and 68.7% of females were recorded with comorbid depression. When the 2007 cohort was compared with the 2017 cohort, a rising trend in depression was observed (5.5% vs 8.2%, P < 0.001). The 2017 cohort of young adults with depression more often consisted of male, non-white patients. The burden of CVD risk factors such as hypertension, diabetes with chronic complications, smoking, and obesity was also greater in the 2017 cohort. Although the all-cause mortality remained comparable (0.3%) in both cohorts, there was a significantly higher rate and risk of MACCE including acute myocardial infarction (aOR 1.18, 95%CI:1.10-1.26), atrial fibrillation or flutter (aOR 1.47, 95%CI:1.40-1.54) and stroke (aOR 1.33, 95%CI: 1.26-1.40) (P < 0.001) in the 2017 cohort. In conclusion, this nationwide study reveals an alarmingly increased prevalence of CVD risk factors and an increase in the rate and risk of MACCE in 2 cohorts of young adults with comorbid depression studied a decade apart. The burden of mental disorders in young adults has been rising in the last decade and warrants extra vigilance by clinicians to recognize and manage depression to curtail CVD risk and improve MACE-associated outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background We aim to compare the burden of cardiovascular disease risk factors and major adverse cardiac events and in-hospital outcomes among young Black patients (aged 18-44 years) hospitalized in 2007 and 2017 using data obtained from the National Inpatient Sample database. Method and Results Comparison of the sociodemographic characteristics, comorbidities, and inpatient outcomes, including major adverse cardiac events (all-cause mortality, acute myocardial infarction, cardiogenic shock, cardiac arrest, ventricular fibrillation/flutter, pulmonary embolism, and coronary intervention), between 2017 and 2007 was performed. Multivariable analyses were performed, controlling for potential covariates. A total of 2 922 743 (mean age, 31 years; 70.3% women) admissions among young Black individuals were studied (1 341 068 in 2007 and 1 581 675 in 2017). The 2017 cohort had a younger population (mean, 30 versus 31 years; P <0.001), more male patients (30.4% versus 28.8%; P <0.001), and patients with higher nonelective admissions (76.8% versus 75%; P <0.001), and showed an increasing burden of traditional cardiometabolic comorbidities, congestive heart failure, chronic pulmonary disease, coagulopathy, depression, along with notable reductions in alcohol abuse and drug abuse, compared with the 2007 cohort. The adjusted multivariable analysis showed worsening in-hospital outcomes, including major adverse cardiac events (adjusted odds ratio [aOR], 1.21), acute myocardial infarction (aOR, 1.34), cardiogenic shock (aOR, 3.12), atrial fibrillation/flutter (aOR, 1.34), ventricular fibrillation/flutter (aOR, 1.32), cardiac arrest (aOR, 2.55), pulmonary embolism (aOR, 1.89), and stroke (aOR, 1.53). The 2017 cohort showed a decreased rate of percutaneous coronary intervention/coronary artery bypass grafting and all-cause mortality versus the 2007 cohort ( P <0.001). Conclusions In conclusion, young Black patients have had an increasing burden of cardiovascular disease risk factors and worsened in-hospital outcomes, including major adverse cardiac events and stroke, in the past decade, although with improved survival odds.

Atherosclerosis is an inflammatory disease that involves antibody immune responses. Progression of hyperlipidemia can lead to atherosclerosis and subsequently cardiovascular diseases with high mortality. Additional lipid-lowering therapies other than statins are currently being studied, such as monoclonal antibodies. In this contemporary review, we examine the various monoclonal antibody therapies targeted toward atherosclerotic disease., (Published by Elsevier Inc.)

Aim: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR., Method: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed., Results: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%)., Conclusion: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma., (© 2022 Association of Coloproctology of Great Britain and Ireland.)

Background: Colorectal cancer management may require an ostomy formation; however, a stoma may negatively impact health-related quality of life (HRQoL). This study aimed to compare generic and stoma-specific HRQoL in patients with a permanent colostomy after rectal cancer across different countries., Method: A cross-sectional cohorts of patients with a colostomy after rectal cancer in Denmark, Sweden, Spain, the Netherlands, China, Portugal, Australia, Lithuania, Egypt, and Israel were invited to complete questionnaires regarding demographic and socioeconomic factors along with the Colostomy Impact (CI) score, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and five anchor questions assessing colostomy impact on HRQoL. The background characteristics of the cohorts from each country were compared and generic HRQoL was measured with the EORTC QLQ-C30 presented for the total cohort. Results were compared with normative data of reference European populations. The predictors of reduced HRQoL were investigated by multivariable logistic regression, including demographic and socioeconomic factors and stoma-related problems., Results: A total of 2557 patients were included. Response rates varied between 51-93 per cent. Mean time from stoma creation was 2.5-6.2 (range 1.1-39.2) years. A total of 25.8 per cent of patients reported that their colostomy impairs their HRQoL 'some'/'a lot'. This group had significantly unfavourable scores across all EORTC subscales compared with patients reporting 'no'/'a little' impaired HRQoL. Generic HRQoL differed significantly between countries, but resembled the HRQoL of reference populations. Multivariable logistic regression showed that stoma dysfunction, including high CI score (OR 3.32), financial burden from the stoma (OR 1.98), unemployment (OR 2.74), being single/widowed (OR 1.35) and young age (OR 1.01 per year) predicted reduced stoma-related HRQoL., Conclusion: Overall HRQoL is preserved in patients with a colostomy after rectal cancer, but a quarter of the patients interviewed reported impaired HRQoL. Differences among several countries were reported and socioeconomic factors correlated with reduced quality of life., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)

Mitral regurgitation is the most common valvular disease in the US and the second most common worldwide. Left untreated, it can lead to the development of heart failure, giving rise to increased mortality rates. Mitral valve intervention is usually indicated in severe mitral regurgitation at the onset of symptoms, even if the function of the left ventricle is preserved. A surgical approach is generally favored according to current guidelines, with excellent clinical outcomes. However, the emergence of novel data from contemporary trials indicates that percutaneous, catheter-based approach may have similar improvements in mortality outcomes while maintaining a superior safety profile when compared to the surgical approach. Here, we discuss transcatheter mitral valve repair as a treatment option for mitral regurgitation and summarize the major clinical trials which were recently conducted on transcatheter repair., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Complex ventral hernias (VHs) represent a real challenge to both general and plastic surgeons. This study aims to compare Sublay Mesh-Only Repair to Posterior Component Separation "PCS" with Transversus Abdominis Release "TAR" in the treatment of complex ventral-wall hernias (VHs)., Methods: This a randomized, controlled, intervention, including two parallel groups: A; Sublay Mesh-Only Repair and Group B; "TAR". Consecutive patients of both genders aged between 18 and 65 years old with complex VHs presented at Mansoura University Hospitals including large-sized abdominal-wall hernia ≥ 10 cm in width, loss of domain ≥ 20%, multiple hernial defects, or recurrent hernias. Immuno-compromised patients, patients with liver impairment, or severe heart failure were considered an exclusion criterion. The primary outcome is the recurrence rate after 12-months following the procedure., Results: Fifty-six patients were recruited in this study. There was no significant difference between both groups regarding recurrence. However, there was significant differences between both groups regarding seroma favoring mesh-only repair., Conclusions: Although TAR may be associated with longer operative times and more blood losses, these were not found to be statistically significant. Postoperative complication, except for seroma, and recurrence rates were comparable in both groups. Trail registration The study was registered on clicaltrials.gov "NCT04516031"., (© 2022. The Author(s).)

Background: Total mesorectal excision (TME) is the gold standard treatment for rectal cancer. Although TME has managed to decrease the rates of local recurrence after rectal cancer resection, local recurrence is still recorded at varying rates. The present study aimed to validate the PREDICT score in the prediction of local recurrence of rectal cancer after TME with curative intent., Methods: This was a retrospective multicenter study on patients with nonmetastatic low or middle rectal cancer who underwent TME. The total PREDICT score was calculated for every patient and related to the onset of local recurrence. According to the final score, patients were allocated to one of three risk groups: low, moderate, and high, and the rates of local recurrence in each group were calculated and compared., Results: The present study included 262 patients (50.4% males) with a mean age of 47.1 years. The overall local recurrence rate was 12.6%. 29.4% of patients were in the low-risk group, 63.7% in the moderate-risk group, and 6.9% in the high-risk group. The local recurrence rate was 3.9% (95% confidence interval [CI]: 0.8-10.9) in the low-risk group, 13.2% (95% CI: 8.4-19.3) in the moderate risk group, and 44.4% (95% CI: 21.5-69.2) in the high-risk group (p < 0.0001). The sensitivity of the PREDICT score was 72.7%, the specificity was 88.1%, and the accuracy was 86.3%., Conclusions: The PREDICT score had good diagnostic accuracy in the prediction of local recurrence after TME and a good discriminatory ability in the differentiation between patients at different risks to develop local recurrence., (© 2022 Wiley Periodicals LLC.)

Background: Non-operative management (NOM) of uncomplicated acute appendicitis (AA) has been introduced as an alternative to appendectomy. This umbrella review aimed to provide an overview of the efficacy and safety of NOM of uncomplicated AA in the published systematic reviews., Methods: This umbrella review has been reported in line with the PRISMA guidelines and umbrella review approach. Systematic reviews with and without meta-analyses on the efficacy of NOM of AA were analyzed. The quality of the reviews was assessed with the AMSTAR 2 tool. The main outcomes measures were the treatment failure and complication rates of NOM and hospital stay as compared to appendectomy., Results: Eighteen systematic reviews were included to this umbrella review. Eight reviews documented higher odds of failure with NOM, whereas two reviews revealed similar odds of failure. Six reviews reported lower odds of complications with NOM, six reported similar odds, and one reported lower odds of complications with surgery. Eight reviews reported similar hospital stay between NOM and appendectomy, one reported longer stay with NOM and another reported shorter stay with NOM. Pooled analyses showed that NOM was associated with higher treatment failure overall, in children-only, adults only, and RCTs-only meta-analyses. NOM was associated with lower complications overall, yet children-only and RCTs-only analyses revealed similar complications to surgery. NOM was associated with shorter stay in the overall and adult-only analysis, but not in the children-only analysis., Conclusions: NOM of AA is associated with higher treatment failure, marginally lower rate of complications and shorter stay than appendectomy., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Transversus abdominis plane (TAP) block is an effective modality for the control of immediate postoperative pain. The present randomized trial aimed to assess the efficacy of ultrasound-guided subcostal TAP (USTAP) and laparoscopic subcostal TAP (LSTAP) block as compared to standard care without TAP block after laparoscopic cholecystectomy., Methods: This was a prospective, randomized, controlled trial on patients who underwent laparoscopic cholecystectomy. Patients were equally randomized to one of three groups: USTAP, LSTAP, and control group (no TAP block). The main outcome measures were pain scores and analgesic consumption within the first 24 h postoperatively, postoperative nausea and vomiting (PONV), time to ambulation, time to first flatus, and adverse effects of TAP block., Results: The trial included 110 patients (90% females) with a mean age of 40.9 ± 11.7 years. Both USTAP and LSTAP block groups were associated with significantly lower pain scores at 2, 6, 12, and 24 h postoperatively, lower cumulative dose of paracetamol, less PONV, and shorter time to flatus than the control group. USTAP and LSTAP block were associated with similar pain scores at all time points, similar analgesic requirements, a similar incidence of PONV, and comparable time to first ambulation and time to first flatus. No adverse effects related to TAP block were recorded., Conclusions: TAP block is a safe and effective method for pain control and improving recovery after laparoscopic cholecystectomy. Both USTAP and LSTAP blocks were equally effective in terms of pain relief, analgesic requirements, PONV, return of bowel function, and time to ambulation., (Copyright © 2022 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

We demonstrate a 13.3 MHz repetition rate, broadband THz source with milliwatt- average power, obtained by collinear optical rectification of a high-power Yb-doped thin-disk laser in the organic crystal BNA (N-benzyl-2-methyl-4-nitroaniline). Our source reaches a maximum THz average power of 0.95 mW with an optical-to-THz efficiency of 4×10 -4 and a spectral bandwidth spanning up to 6 THz at -50 dB, driven by 2.4 W average power (after an optical chopper with duty cycle of 10%), 85 fs-pulses. This high average power excitation was possible without damaging the crystal by using a diamond-heatsinked crystal with significantly improved thermal properties. To the best of our knowledge, this result represents the highest THz average power reported so far using the commercially available organic crystal BNA, showing the potential of these crystals for high average power, high repetition rate femtosecond excitation. The combination of high power, high dynamic range, high repetition rate and broadband spectrum makes the demonstrated THz source highly attractive to improve various time-domain spectroscopy applications. Furthermore, we present a first exploration of the thermal behavior of BNA in this excitation regime, showing that thermal effects are the main limitation in average power scaling in these crystals.

Purpose . The primary aim of the study was to review the existing literature about patient-reported outcome measures (PROMs) in colorectal cancer and IBD. The secondary aim was to present a road map to develop a core outcome set via opinion gathering using social media. Method . This study is the first step of a three-step project aimed at constructing simple, applicable PROMs in colorectal surgery. This article was written in a collaborative manner with authors invited both through Twitter via the #OpenSourceResearch hashtag. The 5 most used PROMs were presented and discussed as slides/images on Twitter. Inputs from a wide spectrum of participants including researchers, surgeons, physicians, nurses, patients, and patients' organizations were collected and analyzed. The final draft was emailed to all contributors and 6 patients' representatives for proofreading and approval. Results . Five PROM sets were identified and discussed: EORTC QLQ-CR29, IBDQ short health questionnaire, EORTC QLQ-C30, ED-Q5-5L, and Short Form-36. There were 315 tweets posted by 50 tweeters with 1458 retweets. Awareness about PROMs was generally limited. The general psycho-physical well-being score (GPP) was suggested and discussed, and then a survey was conducted in which more than 2/3 of voters agreed that GPP covers the most important aspects in PROMs. Conclusion . Despite the limitations of this exploratory study, it offered a new method to conduct clinical research with opportunity to engage patients. The general psycho-physical well-being score suggested as simple, applicable PROMs to be eventually combined procedure-specific, disease-specific, or symptom-specific PROMs if needed.

We present a real-time THz imaging method using a commercial fiber-coupled photo conductive antenna as the THz source and an uncooled microbolometer camera for detection. This new combination of state-of-the-art components is very adaptable due to its compact and uncooled radiation source, whose fiber coupling allows for a flexible placement. Using a camera with high sensitivity renders real-time imaging possible. As a proof-of-concept, the beam shape of a THz Time Domain Spectrometer was measured. We demonstrate real time imaging at nine frames per second and show its potential for practical applications in transmission geometry covering both material science and security tasks. The results suggest that hidden items, complex structures and the moisture content of (biological) materials can be resolved. We discuss the limits of the current setup, possible improvements and potential (industrial) applications, and we outline the feasibility of imaging in reflection geometry or extending it to multi-spectral imaging using band pass filters.

Background: Total mesorectal excision is the gold standard treatment of mid- and low-lying rectal cancer. Lateral pelvic lymph node dissection has been suggested as an approach to decrease recurrence and improve survival. Our meta-analysis presented here aimed to review the current outcomes of lateral pelvic lymph node dissection and total mesorectal excision in comparison with total mesorectal excision alone., Methods: A systematic literature search querying electronic databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We reviewed articles that reported the outcomes of lateral pelvic lymph node dissection combined with total mesorectal excision in comparison with total mesorectal excision alone. The main outcome measures were local recurrence, distant metastasis, overall and disease free-survival, and complications., Results: This systematic review included 29 studies of 10,646 patients. Of those patients, 39.4% underwent total mesorectal excision with lateral pelvic lymph node dissection. The median operation time for the lateral pelvic lymph node dissection + total mesorectal excision was significantly longer than total mesorectal excision alone (360 minutes versus 294.7 minutes, P = .02). Lateral pelvic lymph node dissection + total mesorectal excision was associated with higher odds of overall complications (odds ratio = 1.48, 95% confidence interval: 1.18-1.87, P < .001) and urinary dysfunction (odds ratio = 2.1, 95% confidence interval: 1.21-3.67, P = .008) than total mesorectal excision alone. Both groups had similar rates of male sexual dysfunction (odds ratio = 1.62, 95% confidence interval: 0.94-2.79, P = .08), anastomotic leakage (odds ratio = 1.15, 95% confidence interval: 0.69-1.93, P = .59), local recurrence (hazard ratio = 0.96, 95% confidence interval: 0.75-1.25, P = .79), distant metastasis (hazard ratio = 0.96, 95% confidence interval: 0.76-1.2, P = .72), overall survival (hazard ratio = 1.056, 95% confidence interval: 0.98-1.13, P = .13), and disease-free survival (hazard ratio = 1.02, 95% confidence interval: 0.97-1.07, P = .37)., Conclusion: Lateral pelvic lymph node dissection was not associated with a significant reduction of recurrence rates or improvement in survival as compared with total mesorectal excision alone; however, LPLND was associated with longer operation time and increased complication rate., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery., Objective: This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence., Design: This is a retrospective review of a prospective database., Setting: This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals., Patients: Adult patients with anal fistula who underwent surgery were included., Interventions: Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure., Main Outcome Measures: The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula., Results: A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant., Limitations: This is a retrospective, single-center study., Conclusion: Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441., Modificacin De La Clasificacin De Parks De La Fstula Anal Criptoglandular: ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441., (Copyright © The ASCRS 2020.)

Proctology is one of the surgical specialties that suffered the most during COVID-19 pandemic. Using data from a cross-sectional worldwide web survey, we aimed to snapshot the current status of proctologic practice in Italy with differences between three macro areas (North, Centre, South). Specialists affiliated to renowned scientific societies with an interest in coloproctology were invited to join a 27-item survey. Predictive power of respondents' and hospitals' demographics on the change of status of surgical activities was calculated. The study was registered at ClinicalTrials.gov (NCT04392245). Of 299 respondents from Italy, 94 (40%) practiced in the North, 60 (25%) in the Centrer and 82 (35%) in the South and Islands. The majority were men (79%), at consultant level (70%), with a mean age of 46.5 years, practicing in academic hospitals (39%), where a dedicated proctologist was readily available (68%). Southern respondents were more at risk of infection compared to those from the Center (OR, 3.30; 95%CI 1.46; 7.47, P = 0.004), as were males (OR, 2.64; 95%CI 1.09; 6.37, P = 0.031) and those who routinely tested patients prior to surgery (OR, 3.02; 95%CI 1.39; 6.53, P = 0.005). The likelihood of ongoing surgical practice was higher in the South (OR 1.36, 95%CI 0.75; 2.46, P = 0.304) and in centers that were not fully dedicated to COVID-19 care (OR 4.00, 95%CI 1.88; 8.50, P < 0.001). The results of this survey highlight important factors contributing to the deadlock of proctologic practice in Italy and may inform the development of future management strategies.

Background: Early-onset colon and rectal cancer has increased in alarming rates. The present study reviewed the characteristics and outcome of early-onset rectal cancer in patients aged ≤40 years., Methods: This was a retrospective cohort study on rectal cancer patients who were treated in a tertiary center in the Middle East. Baseline characteristics and outcomes of patients ≤40 years were compared with patients >40 years. Main outcome measures were patients' and tumor characteristics, local recurrence, distance metastasis, overall survival (OS), and disease-free survival (DFS)., Results: Among 244 patients with rectal cancer, 81 (33.2%) aged 40 years or less. 56.8% of patients ≤40 years and 49.7% of patients >40 years presented with stage III/IV disease (p = 0.36). Local recurrence and distant metastasis were detected in 10.3% and 13.2% of patients ≤40 years and in 16.9% and 13.9% of patients >40 years (p = 0.29 and 0.88). The 3-year OS and DFS rates of patients ≤40 years were 75% and 80.9% versus 74.2% and 76.5% in patients >40 years (p = 0.9 and 0.59). Patients ≤40 years presented with ulcerative carcinoma (38.3% vs 21.5%, p = 0.01) and signet-ring carcinoma (12.3% vs 2.5%, p = 0.008) more than patients > 40 years., Conclusion: Early-onset rectal cancer accounted for one-third of all patients presenting with rectal cancer. Patients younger than 40 years had higher incidence of mucinous and signet-ring rectal carcinoma, and presented more with advanced stage. The age of patients did not have a significant impact on the oncologic outcome of rectal cancer., Competing Interests: Declaration of competing interest None., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

The fundamental properties of water molecules, such as their molecular polarizability, have not yet been clarified. The hydrogen bond network is generally considered to play an important role in the thermodynamic properties of water. The terahertz (THz) Kerr effect technique, as a novel tool, is expected to be useful in exploring the low-frequency molecular dynamics of liquid water. Here, we use an intense and ultrabroadband THz pulse (peak electric field strength of 14.9 MV/cm, centre frequency of 3.9 THz, and bandwidth of 1-10 THz) to resonantly excite intermolecular modes of liquid water. Bipolar THz field-induced transient birefringence signals are observed in a free-flowing water film. We propose a hydrogen bond harmonic oscillator model associated with the dielectric susceptibility and combine it with the Lorentz dynamic equation to investigate the intermolecular structure and dynamics of liquid water. We mainly decompose the bipolar signals into a positive signal caused by hydrogen bond stretching vibration and a negative signal caused by hydrogen bond bending vibration, indicating that the polarizability perturbation of water presents competing contributions under bending and stretching conditions. A Kerr coefficient equation related to the intermolecular modes of water is established. The ultrafast intermolecular hydrogen bond dynamics of water revealed by an ultrabroadband THz pump pulse can provide further insights into the transient structure of liquid water corresponding to the pertinent modes., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© The Author(s) 2020.)

Background: Chronic anal fissure (CAF) is a common painful anal condition. Medical treatment of CAF involves the use of agents that induce chemical sphincterotomy. The present trial aimed to compare the efficacy and safety of topical minoxidil and glyceryl trinitrate (GTN) preparations in treatment of CAF., Methods: Adult patients with CAF were randomly assigned to one of two equal groups; group I received topical 5% minoxidil gel and group II received topical 0.2% GTN cream. The main outcome measures were healing of anal fissure, duration to healing, relief of symptoms, and adverse effects., Results: 62 patients (36 female and 26 male) were included to the study. Group I comprised 30 patients and group II comprised 32 patients. Healing of anal fissure was achieved in 23 (76.7%) patients in group I and 15 (46.9%) patients in group II (p = 0.03). The average duration to healing in group I was significantly shorter than group II (4.1 ± 1.9 vs 5.3 ± 2.7 weeks, p = 0.048). Adverse effects were recorded in 2 (6.6%) patients in group I and 13 (40.6%) patients in group II. The post-treatment pain score in the GTN group was significantly lower than the Minoxidil group., Conclusion: Topical 5% minoxidil gel achieved greater and quicker healing of CAF and fewer adverse effects than topical 0.2% GTN cream. Post-treatment pain scores after GTN were significantly lower than minoxidil., Trial Registration Number: NCT03528772., Competing Interests: Declaration of competing interest None., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Charge transfer across the interface and interlayer coupling in the graphene van der Waals heterostructure, which is constructed by graphene and semiconducting transition metal dichalcogenides (TMDCs), is critical for their electronic and optoelectronic applications. Photo-induced charge injection from TMDC to graphene has been studied in several heterostructure photodetectors. However, the response time significantly varies among different reports, ranging from microseconds to milliseconds. In this work, using a graphene/WSe 2 heterostructure as an example, we directly observe the carrier density change in graphene by time-resolved optical-pump terahertz (THz)-probe spectroscopy and show the ultrafast picosecond photoresponse of graphene. In the absence of photoexcitation, THz time-domain spectroscopic measurements show that WSe 2 can transfer holes to graphene and pull down the Fermi level of graphene. After excitation by the ultrafast laser pulse, the transient THz response shows a rapid (∼0.35 ps) increase in the graphene conductivity mainly due to the hole injection from WSe 2 into graphene. Unlike previous reports on band bend as the guidance mechanism for charge transfer, our results show that the relevant mechanism is the band offset across the atomically sharp interface.

Background: Morbid obesity is associated with variable degrees of pulmonary dysfunction that may predispose to postoperative complications. This study aimed to identify high risk patients to have pulmonary dysfunction before bariatric surgery in terms of age, sex, and body mass index (BMI) and the impact of pulmonary dysfunction on postoperative pulmonary complications. Methods: Prospective database of patients with morbid obesity who underwent bariatric surgery was reviewed. Data on patients' demographics, parameters of pulmonary function tests, and postoperative pulmonary complications were collected. The correlation between patients' age, sex and BMI, and pulmonary function was investigated using Pearson's correlation coefficient test. Results: Ninety-seven patients (82 female) with morbid obesity were included in the study. Twenty-eight (28.9%) patients had pulmonary dysfunction. Patients >40 years had higher odds of pulmonary dysfunction than patients ≤40 years (odds ratio [OR]: 2.54, P  = .05). Male patients had significantly higher odds of pulmonary dysfunction than female patients (OR: 2.5, P  = .03). Patients with BMI >50 had significantly higher odds of pulmonary dysfunction than patients with BMI <50 (OR: 4.9, P  = .002). Patients with pulmonary dysfunction had significantly higher odds of developing pulmonary complications than patients with normal spirometry (OR: 9.13, P  = .009). Conclusion: Around 30% of patients undergoing bariatric surgery had pulmonary dysfunction. Pulmonary dysfunction in preoperative spirometry was able to predict postoperative pulmonary complications. Men, patients older than 40 years, and superobese individuals had higher odds of having pulmonary dysfunction and are at higher risk to develop pulmonary complications after bariatric surgery.

Background: Complex anal fistula is one of the challenging anorectal conditions. Several treatments have been proposed for complex anal fistula, yet none proved to be ideal., Objective: This randomized trial aimed to assess the efficacy of external anal sphincter-sparing seton in comparison with the conventional drainage seton in the treatment of complex anal fistula., Design: This was a prospective, randomized, single-blind controlled study., Settings: The study was conducted at the Colorectal Surgery Unit of Mansoura University Hospitals., Patients: Adult patients of both sexes with complex anal fistula were recruited and evaluated with MRI before surgery., Interventions: Patients were randomly divided into 2 groups; group 1 was treated with conventional drainage seton and group 2 was treated with external anal sphincter-sparing seton using a rerouting technique., Main Outcome Measures: The duration of healing, incidence of recurrence or persistence, postoperative pain, and complications including fecal incontinence were measured., Results: Sixty patients (56 men) with a mean age of 43 years were included. Mean operation time in group 1 was significantly shorter than group 2 (29.8 ± 4.3 vs 43.8 ± 4.5 min; p < 0.0001). The mean pain score at 24 hours in group 1 was 8.1 ± 1.6 versus 5.3 ± 1.3 in group 2 (p < 0.0001). Five patients (17%) in group 1 experienced complications versus 2 (7%) in group 2. All of the patients in group 1 required a second-stage fistulotomy versus 2 patients (7%) in group 2 (p < 0.0001). Time to complete healing in group 1 was significantly (p < 0.0001) longer than group 2 (103 ± 47 vs 46 ± 18 d). Four patients (13%) in group 1 and 1 patient (3%) in group 2 experienced persistence or recurrence of anal fistula (p = 0.35)., Limitations: This was a single-center study with relatively small numbers in each group., Conclusions: Patients treated with external anal sphincter-sparing seton after rerouting of the fistula tract achieved quicker healing and less postoperative pain than those with conventional drainage seton. Postoperative complication and recurrence rates were comparable in both groups. See Video Abstract at http://links.lww.com/DCR/A963., Trial Registration: clinicaltrials.gov identifier: NCT03636997 (https://clinicaltrials.gov/ct2/show/NCT03636997).

Background: Laparoscopic ventral mesh rectopexy (LVMR) has proved effective in the treatment of internal and external rectal prolapse. The present meta-analysis aimed to determine the predictive factors of recurrence of full-thickness external rectal prolapse after LVMR., Methods: An organized, systematic search of electronic databases including PubMed/Medline, Embase, Scopus, and Cochran library was conducted in adherence to PRISMA guidelines. Studies that reported the outcome of LVMR in patients with full-thickness external rectal prolapse were included according to predefined criteria. A meta-regression analysis and sub-group meta-analyses were performed to recognize the patient and technical factors that were associated with higher recurrence rates., Results: Seventeen studies comprising 1242 patients of a median age of 60 years were included. The median operation time was 122.3 min. Conversion to open surgery was required in 22 (1.8%) patients. The weighted mean complication rate across the studies was 12.4% (95% CI 8.4-16.4) and the weighted mean rate of recurrence of full-thickness external rectal prolapse was 2.8% (95% CI 1.4-4.3). The median follow-up duration was 23 months. Male gender (SE = 0.018, p = 0.008) and length of the mesh (SE = - 0.007, p = 0.025) were significantly associated with full-thickness recurrence of rectal prolapse. The weighted mean rates of improvement in fecal incontinence and constipation after LVMR were 79.3% and 71%, respectively., Conclusion: LVMR is an effective and safe option in treatment of full-thickness external rectal prolapse with low recurrence and complication rates. Male patients and length of the mesh may potentially have a significant impact on recurrence of rectal prolapse after LVMR.

Background: Based on the promising results of transversus abdominis plane (TAP) block in various abdominal procedures, this study aimed to investigate its effect on postoperative pain and early outcome after laparoscopic bariatric procedures., Methods: Patients with morbid obesity were randomly assigned to one of two equal groups; group I had US-guided TAP block upon completion of the bariatric procedure and before recovery from general anesthesia and group II did not have TAP block. All procedures were performed laparoscopically with a standardized five-trocar technique., Results: Ninety-two patients of a mean age of 34.7 years and mean BMI of 49.5 kg/m 2 were included. The mean pain score in group I was significantly lower than group II at 1 and 6 h postoperatively, whereas no significant differences in pains scores at 12 and 24 h between the two groups were observed. Eight patients in group I required rescue opioid analgesia within the first 24 h postoperatively, compared with 24 patients in group II (P < 0.0001). The postoperative nausea and vomiting (PONV) score at 24 h was significantly lower in group I than group II. Group I required a significantly shorter time to full ambulation and to pass flatus compared with group II. Hospital stay was similar in the two groups., Conclusion: Using US-guided TAP block in adjunct with laparoscopic bariatric surgery managed to achieve lower pain scores, lower opioid requirements, lower PONV scores, earlier ambulation, shorter time to pass flatus, and comparable hospital stay and complication rate to the control group.

Background: Treatment of complex anal fistula (CAF) can be associated with high rates of recurrence and fecal incontinence (FI). Park suggested drainage of the affected intersphincteric anal gland for treatment of cryptoglandular anal fistula; however, recurrence after this technique was high. We modified the original Park's technique by extending the internal sphincterotomy to ensure adequate drainage of the intersphincteric space. The aim of this study was to evaluate the incidence of recurrence and FI after modified Park's technique in treatment of CAF., Methods: Adult patients of both genders with CAF were evaluated before undergoing modified Park's technique with Wexner continence score, clinical examination, and endoanal ultrasonography or MRI. Postoperatively, patients were examined every 2 wk until complete wound healing. The continence state was evaluated with Wexner continence score, and quality of life was assessed before surgery and at 6 mo postoperatively by Short Form-36 questionnaire., Results: Thirty-two patients (27 male) of a mean age of 38 y were included. Median follow-up was 12 mo. Two patients (6.25%) experienced recurrence and 5 (15.6%) developed complications. One patient (3.1%) developed new-onset FI postoperatively. Twenty-eight (87.5%) patients were completely satisfied with the procedure. Quality of life showed significant improvement at 6 mo postoperatively., Conclusions: The modified Park's technique is a promising procedure for the treatment of CAF with low recurrence and FI rates, and improved quality of life., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Anastomotic leakage is considered the commonest major complication after surgery for rectal cancer., Materials and Methods: Patients who underwent laparoscopic LAR or ULAR for rectal cancer were recruited. The primary outcome was the incidence of the AL during 30 days postoperative., Results: Fifty-nine consecutive patients were included in the study. Fifty-three patients underwent LAR with stapled colorectal anastomoses, while the remaining 6 patients underwent ULAR with hand-sewn coloanal anastomoses. The median duration of operation was 195 minutes (range; 120-315). The defunctioning ileostomy was created in 24 (7%) patients. Overall, there was no recorded mortality. Only 10 (17%) patients developed complications. There were only 4 patients who developed AL. Three patients had a subclinical AL as they had defunctioning ileostomy at the time of the initial procedure, the diagnosis was made by CT with rectal contrast. They were treated conservatively with transanal anastomotic drainage under endoscopic guidance. One patient had a clinically significant AL, demonstrated as a peritonitis. This patient required reoperation during which pelvic abscess was drained, resection of the previous anastomosis, and hartmann's colostomy was performed., Conclusion: Standardization of a definition, as well as, criteria for the diagnosis of AL, will help in comparison of the results and the surgical techniques in order to optimize the required care offered to rectal cancer patients. On expert hands, it is feasible to perform a laparoscopic sphincter-saving total mesorectal excision, additionally, it provides the advantages of a clear view of the deep pelvis and facilitates a precise sharp dissection., Key Words: Anastomosis, Anastomotic Leakage, Rectal cancer, Total mesorectal excision.

Background: Although conventional hemorrhoidectomy proved effective in treatment of hemorrhoidal disease, postoperative pain remains a vexing problem. Alternatives to conventional hemorrhoidectomy as transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidopexy (SH) were described. The present meta-analysis aimed to review the randomized trials that compared THD and SH to determine which technique is superior in terms of recurrence of hemorrhoids, complications, and postoperative pain., Methods: Electronic databases were searched for randomized trials that compared THD and SH for internal hemorrhoids. The PRISMA guidelines were followed when reporting this meta-analysis. The primary endpoint of the analysis was persistence or recurrence of hemorrhoidal disease. Secondary endpoints were postoperative pain, complications, readmission, return to work, and patients' satisfaction., Results: Six randomized trials including 554 patients (THD = 280; SH = 274) were included. The mean postoperative pain score of THD was significantly lower than SH (2.9 ± 1.5 versus 3.3 ± 1.6). 13.2% of patients experienced persistent or recurrent hemorrhoids after THD versus 6.9% after SH (OR = 1.93, 95%CI = 1.07-3.51, p = 0.029). Complications were recorded in 17.1% of patients who underwent THD and 23.3% of patients who underwent SH (OR = 0.68, 95%CI 0.43-1.05, p = 0.08). The average duration to return to work after THD was 7.3 ± 5.2 versus 7.7 ± 4.8 days after SH (p = 0.34). Grade IV hemorrhoids was significantly associated with persistence or recurrence of hemorrhoidal disease after both procedures., Conclusion: THD had significantly higher persistence/recurrence rate compared to SH whereas complication and readmission rates, hospital stay, return to work, and patients' satisfaction were similar in both groups.

Purpose: We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL)., Methods: Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL., Results: Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20-35 kg/m2 ). The median tumor distance from the anal verge was 8 cm (range, 4-12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation., Conclusion: These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.

The authors of the published version of this article missed to add the second affiliation of Mostafa Shalaby. The new affiliation is now added and presented correctly in this article. The remainder of the article remains unchanged.

Background: Sacrococcygeal pilonidal disease (SPD) is a common surgical condition for which a multitude of surgical treatments have been described. The present review aimed to evaluate the efficacy and safety of a novel endoscopic procedure for the treatment of SPD., Methods: An organized literature search was conducted. Electronic databases including PubMed/Medline, Scopus, Embase, and Cochrane library were searched for articles that assessed the endoscopic treatment for SPD. The main outcome parameters were failure of the technique including persistence and recurrence of SPD, postoperative complications and pain, time to complete healing, and time to return to work., Results: Nine studies with a total of 497 patients were included. Mean age of patients was 24.8 years. Mean operation time was 34.7 min. The procedure was performed as day-case surgery in all studies. The mean Visual analogue score of pain within the first week was 1.35. Failure of the technique was recorded in 40 (8.04%) patients, 20 (4.02%) had persistent SPD and 20 (4.02%) developed recurrence. The weighted mean failure rate of the technique was 6.3% (95% CI 3.6-9.1). Mean weighted complication rate was 1.1% (95% CI 0.3-2.4). Mean time to complete healing was 32.9 days and mean time to return to work was 2.9 days., Conclusion: The endoscopic treatment of pilonidal sinus is a promising and safe method of treatment of SPD. The main advantages of the endoscopic treatment as compared to conventional surgery are the minimal postoperative pain, quick healing, and short time to return to work and daily activities.

The authors of the published version of this article missed to add the second affiliation of Mostafa Shalaby. The new affiliation is now added and presented correctly in this article. The remainder of the article remains unchanged.

Purpose: "Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis., Methods: We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed., Results: Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days., Conclusions: Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Aim: This study aims to compare the early and late outcomes of transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) for the treatment of hemorrhoidal disease., Methods: From January 2013 to December 2014, 100 patients-50 patients on each arm-were randomly allocated to THD or SH groups. The inclusion criteria were grade III and IV hemorrhoids diagnosed by clinical examination and proctoscopy. The primary outcome was to compare the recurrence rate with a minimum follow-up of 2 years, and the secondary outcome was to compare complications rate, time to return to work postsurgery, procedure length, and patient's satisfaction between the 2 techniques., Results: The mean follow-up period was 33.7 ± 7.6. The recurrence rate was 4% in the SH group and 16% in the THD group ( P = .04). There was no difference in the intraoperative and postoperative complications rate; the pain score was significantly higher in the THD group. The mean operative time was significantly shorter in the SH group compared with the THD group. Patients in the THD group returned to work or routine activities significantly later compared with patients in the SH group. The overall satisfaction rate was also higher in the SH group., Conclusion: Both procedures are simple and easy to perform for the treatment of grade III and IV hemorrhoids. SH showed better results in terms of lower rate of recurrence, lower postoperative pain, quicker return to work, and higher patient satisfaction.

Background: Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive technique for the treatment of fistula-in-ano (FIA). This review aimed to search the literature for the outcome of VAAFT regarding the recurrence and complication rates of the technique., Methods: A systematic literature search was conducted in compliance with the PRISMA screening guidelines. PubMed/MEDLINE and Scopus were searched for articles reporting the outcomes of VAAFT procedure from inception through April 2017. The main outcomes were patients' characteristics, technical aspects, operation time, recurrence, and complication rates., Results: Eleven studies (n = 788 patients) were included. The mean age of the patients was 39.5 years. 66.5% of patients had high or complex FIA and 18.4% underwent previous fistula surgery. The internal opening of the fistula was detected in 85.7% of patients. The mean operation time was 42 ± 14.2 min. The weighed mean rate of detection of internal opening was 93.3%. Recurrence occurred in 112 (14.2%) patients after a median follow-up of 9 months. Recurrence rates varied according to method of closure of internal opening from 15.3% after using staplers, 17.7% after suturing, to 25% after advancement flap. The weighted mean recurrence rate across the studies was 17.7%. The weighted mean complication rate was 4.8%., Conclusion: VAAFT may be considered an effective diagnostic tool and a safe method for the treatment of complex and high FIA attaining satisfactory outcome and acceptably low complications. Recurrence after VAAFT may be related to previous fistula surgery and the method of closure of the internal opening.