Colorectal Surgery

Dear distinguished colleages.Patient’s life isn’t a tradition. Regarding the metaanalysis and statistics ,I have read and I totally informed. However I saw with my own eyes in the U.S. and Europe colleagues in the patient study does not report all the complications in the medical records. What are these type of studies? Everyone knows that surgeons are not recorded objectively their complications. On this basis one can assume that the published studies have large error rate. On the other hand with my personal experience ten of about three hundred cases where the intestinal anastomoses were unprepared showed leakage. For me leakage is a life threatening complication especially in the half of the cases that I was need to reoperate them as we faced with an inflammatory disaster. So I stronger believe that only meticulous mechanical preparation is a presupposition for a succesful operation. And believe us that’s not a tradition. P.S We’ve never experienced leakage in a prepared colon. Drain were neseccary in the other 5 cases as they formatting a fistulous tract through it the fecal output gradually was minimized and eliminated. Thank you for this valuable discussion.

Stoma to be made in LAR

....any bleeding tissues due to damage of significant-sized vessels will be mechanically affected by Hypertension....bleeding Haemoorhoids Is An example

Thank you! So, it was transsphincteric one? Accept my greetings in this case! I have never seen things like that before. I fancy, could not it be a case of the acute anterior paraproctitis from the very beginning, not the Bartholin abscess? By the way, what is your own opinion, are there any reliable diffential diagnostics criteria between a bartholinitis and anterior paraproctitis? And, besides, are there any anatomical data about a bartholin gland location, structure, embryological development, macerational preparations at all in literature? As for me, I have not met works of this sort. I am not confident in Gynecology, though.

Diverticular bleeding of the colon is very difficult to locate with endoscopic examination. In case of severe bleeding, too blood limits the procedure, in case of stop bleeding there isn't nothing to see. A contrast CT scan in emergency setting should be considered

Perineal hernias after aper were seen in about 8% patients. Omentopexy and soft tissue closure alone do not prevent perineal hernias. No Patient with pelvic floor reconstruction (flaps/mesh) developed perineal hernia. However incidence of wound infection and dehiscence ( p=ns) seemed higher after biological mesh. PPT attached

We have used the standard TEM the SILS port (covidien) and the TAMIS platform we like the TAMIS and SILS ports because we can use standard laparoscopic instruments and energy devices. The SILS limitations have be with keeping the port inside and keeping insufflation. The TAMIS works very well and has a kit that is available for practice and teaching of residents. The ability to move between platforms has worked best for our patients but the TAMIS port seems to be the easiest to use.

Dear Dr. Julianov, The answer for this question is rather difficult, because too much scenario exists and it means that there is not an appropriate trial design can be set up. I beleive that the most important is the work of a multidisciplinary team, because the treatment of a resectable distant metastases and the management of the local rectal malignant lesion is different. There are basically four scenarios: 1st: liver met is small and resectable, rectal cancer is under T3. Probably the appropriate choice is the synchronous resection of liver and rectal malignancy. 2nd: liver met needs preop chemo, rectal cancer is under T3. I guess, the best choice is delivering preop chemo than synchronous resection 3rd: liver met is small and resectable and can be fit for local treatment, rectal cancer is T3 or over it (like N1 or T4). I would go for local procedures for liver met like RFA, and I would deliver state of the art chemoradiation for rectal cancer before operation of both and the most difficult situation when liver met needs preop treatment and rectal cancer also needs preop chemoradiation. my current practice is out of evidence based outlined procedures: I used to start the preoperative chemoradiation for rectal cancer, the long course naturally, and biweekly I used to insert cycles od systemic chemo (usually FOLFOX4) for systemic control. After finishing the sandwich like chemoradiation therapy, patient can be almost promptly operated for the liver stuff, followed by the in-time ractal cancer surgery.

The first Dutch study was aborted because of high rate of complications, but other three study are on going. The UK CReST Trial, a second Dutch trial and a swedish trial. I think that we have to wait these results for better understanding the value of the procedure.

It does not seem one technique to have significant benefits compared to another. Only for right colectomy for cancer stapled side-to side anastomosis showed marginally better results, however I personally never use it. You can look at two most recent systematic reviews on the subject: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3536859/pdf/WJGS-4-208.pdf http://archsurg.jamanetwork.com/article.aspx?articleid=1654856

My answer to HALS as a bridge to total laparosocopic surgery is NO. And YES to HALS as a complimentary procedure in some situations. If you are learning a new lap procedure its always better to do it all in laparoscopic way with no HALS in the back of your mind. If you plan to use it to make things easier it might be usefull. I am not sure if in obese patients it gives any additional benefit. Any way, it was thought of to make surgeries easier during their learning curves. Though, don't you think it is a kind of cheating ;)))

This is just part of a package of measures to minimise the disturbance to physiology through either open or laparoscopic surgery and calorific nutrition may be given either as food or nutritional supplements that are absorbed in the upper small bowel.

Dear Peter, is this protocol of your Department available somehow?

Fatih: Thanks for your feedback, and for introducing the springboard for these intriguing issues. Let me therefore try to further clarify my intention in my commentary above. The discussion and implications I marshaled were general: the interspecies differences observed are critically consequent to phase II metabolic divergence, and hence circulating concentration levels of the biologically active unconjugated genistein, shown to be massively higher in rodent models and strains than in humans human tumors; the specific strains referenced in the studies I cited have not been demonstrated to differ in the dynamics of Phase II metabolism from rodent species metabolic dynamics in general, they just happen to be the only strains for which - at least to date - we have rodent-human relative concentration ratios (from 20 to 150 fold) comparisons, as cited. Thus, the seminal study from Liliane Massaad's team compared the main phase I and phase II drug-metabolizing enzyme systems in both tumoral and nontumoral colon tissues, and found that for most phase II drug-metabolizing pathways the mouse model (via the widely used mouse colon adenocarcinoma Co38 model), was qualitatively and quantitatively different from human colon tissues, concluding that the drug-metabolizing enzyme systems of rodents versus humans in both tumoral and nontumoral colon tissues are so markedly divergent that this non-translatability can dramatically influence the sensitivity of organs or tissues to any under-study anti-cancer effects so as to differentially determine tumor response to anticancer agents, natural or traditional. Hence, unless we have dispositive data to show that any particular rodent strain, say Sx, is NOT subject to the same rodent-human divergence in Phase II metabolism, than any extrapolation from rodent to human remains tainted. Since the data show that the Phase II glucuronidation of genistein sharply distinguishes rodent from human models, this induces proportionately high circulating plasma concentrations of biologically active unconjugated genistein in rodents that are not correspondingly physiologically achievable in humans who are "ultra-metabolizers" in Phase II kinetics and dynamics and hence present (humans) with maximal and highly efficient clearance of these active forms. The profoundly inefficient rodent clearance-metabolism of isoflavones in turn leaves many fold higher concentrations, and as I noted, the studied dose-dependencies of genistein are non-linear in the upper ranges, allowing for either strongly stimulatory, or strongly inhibitory, effects depending on where in the non-linear space the higher concentrations fall. And neither effect - tumor-inhibition versus tumor-stimulation - has been established as more probable, as we have studies divided on showing either one of these, the phenomenon of non-linear upper-range dose-dependency most powerfully demonstrated by Siyuan Zhou and colleagues who showed that the absorption, biotransformation, and excretion of high doses of genistein occurred in a nonlinear dose-dependent manner (cited above, this non-linear dose dependency ("ceiling" effect) also confirmed in the dietary isoflavone / colorectal adenoma risk study from the National Cancer Center in Japan (Akhter et al, Br J Cancer, 2009)). The totality of these findings calls into question rodent modeling of isoflavone antitumor activity, a suspicion confirmed by the fact that the observations seen in the rodent models are wholly dissonant with, and contradicted by, human clinical data, primarily consequent to the radical divergence of Phase II metabolisms for isoflavones (including genistein, diadzein, and equol (a diadzein-bacterial derivative)) [note: this is agent-specific - other agents may have largely congruent metabolic kinetics and dynamics between rodent and human models, but isoflavones decidedly do not].

Defunctioining seems to work. I think it must be personal preference but still believe that ileostomy is supported by some kind of evidence. Bowel prep or not does not seem to make incidence of leak worse (see thread after other question on this site regarding that point). I can't see the logic in the arguments around ileostomy if prepped and colostomy or not. If the bowel is non prepped then there will be some stool above the anastamosis no matter where the proximal defunction is (and there is only 30-40cm or so difference between ileostomy an transverse defunctioning colostomy, leaving more than enough faeces distally to cause sepsis and death if moving through the leak). The bottom line here is that there is no need to prep the colon. if there is no need, we shouldn't do it (all interventions can cause complications).

I agree with Dr. Memon. The goal of internal sphincterotomy is to relieve the hypertonus of the internal sphincter in order to stop the vicious circle: pain-spasm-impaired blood flow & healing-pain. I do LIS in an outpatient ambulatory practice under local anesthesia for more than 15 years. The lengths of the fissure or the dentate line are not important landmarks in LIS for me, as the effect of the procedure is related only to the relaxation achieved with it. To achieve good relaxation in my practice is usually sufficient to cut 50-60% of the length of the IS. I never experienced a post-LIS incontinence of any grade following this rule. However in about 5% of pts the fissure not healed with or without symptoms and another procedure may be necessary at the opposite side. The digital examination of the sphincter is the key when considering LIS, as you can face with fissures without spasm of the IS and surely LIS should be avoided in these patients.

In my experience when I had to repair left iliac parastomal hernias I realized that the incidence of the hernias was remarkably lower if the stoma was created bringing attention to the "lateral-space obstruction". The lateral space has to be tightly closed securing the descending colon to the parietocolic wall (either with interrupted stitches or a purse-string suture) or using the Goligher technique of extraperitoneal colostomy. I personally believe that a careful attention to the "lateral-space obstruction" is one of the major factors in the prevention of parastomal hernias.

Thank you very much sir. Its been a good job I will be expecting what you promised for sharing with colleagues Adebimpe Aderounmu