Colon Stump Research Articles

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis

BackgroundRobotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes.MethodsFrom September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3.In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3–0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique.ResultsThe matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien–Dindo grade III or any anastomosis-related complications.ConclusionsThe RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

Modified delayed coloanal anastomosis following TME for mid and low rectal cancer: 19 consecutive patients from a single center.

Surgery and management of rectal cancer have made significant progress in recent decades. However, there is still no coloanal anastomosis technique that offers a good compromise between functionality and low morbidity. The aim of this study is to evaluate the safety and efficiency of the modified delayed coloanal anastomosis (mDCA). In this retrospective study, we analyzed the morbi-mortality as well as functional outcomes of 19 patients treated with mDCA, out of 73 colorectal cancer patients treated at our institution from September 2021 to June 2023. The inclusion criteria were cancer of the mid and low rectum (tumor less than 10cm from the anal verge). Morbidity represented by complications of Clavien-Dindo grade III or higher was estimated at 5.2%. Only one patient experienced an asymptomatic anastomotic leak (AL) grade A. Ischemia of the colonic stump occurred in one patient, taken back to the OR on the 5th postoperative day. No stump retraction was noted. Anastomotic stenosis appeared in one patient (5.2%) during the 90-day postoperative period, and was treated by instrumental dilation. Perioperative mortality was nil. The mean St Marks incontinence score at 90days was 13.2 points. At the 3-month follow-up, 15 patients (78.9%) had major low anterior resection syndrome (LARS), three (15.7%) had minor LARS, and one patient (5.2%) had no LARS. None of the patients had a diversion loop ileostomy. The mDCA, by decreasing the rate of AL, without the need for diversion ileostomy, might be an interesting alternative to the conventional immediate coloanal anastomosis (ICA), for restoring the GI tract after proctectomy for cancer.

Robotic CME in 110 consecutive cases: feasibility and short-term technical and oncological outcomes.

Complete mesocolic excision (CME) has been introduced from open surgery, to compare right colon cancer surgery to total mesorectal excision for rectal cancer and it is currently being applied by robotic approach. CME concept is based on the complete removal of right mesocolon and the dissection deep at the level of the central feeding vessels. Aside the CME, intracorporeal anastomosis completes a total minimally invasive approach to the treatment of right colon cancer. This study retrospectively analyzed the feasibility and efficacy of robotic CME and intracorporeal anastomosis in a cohort of consecutive patients affected with right colon cancer. The data of 110 patients undergone a robotic CME with IA anastomosis for right colon cancer from 2018 to 2023 were prospectively collected and retrospectively analyzed. Intraoperative, postoperative, and short-middle term outcomes were considered for analysis, as well as pathologic and oncologic outcomes. A time-to-event analysis was performed using the Kaplan-Meier method for OS and DFS. All patients underwent a robotic right colectomy. Median operative time was 184 min, blood loss was negligible, no intraoperative complications occurred. Three conversions (2.7%) were experienced due to bulky lymph nodes and severe local advanced tumor. Mean postoperative stay was 6 days. Six postoperative complications occurred, 4 postoperative ileus, 1 late dehiscence of the colonic stump and an iatrogenic colonic perforation. The latter needed reintervention. Robotic CME with central vessels ligation seems feasible and safe, with acceptable morbidity and adequate short-middle term outcomes.

A sutureless overlapped anastomosis technique using linear staplers with reinforced bioabsorbable material in robotic right colectomy with intracorporeal anastomosis.

Creation of an overlapped anastomosis using handsewn sutures for common enterotomy is very popular in robotic right colectomy (RRC) with intracorpareal anastomosis (IA). The aim of this study is to present a simple method for constructing a sutureless overlapped anastomosis using a 60 mm linear stapler with a reinforced bioabsorbable material in RRC with IA. The distal ileum and proximal colon were put in overlapping positions. Enterotomies were created 2 cm proximal to the ileal stump and 8 cm distal to the colonic stump on the antimesenteric side. Subsequently, a 60 mm linear stapler with a reinforced bioabsorbable material was inserted into each lumen and fired. Finally, the bowel was elevated while holding the bioabsorbable material, and the common enterotomy was grasped with the robotic instrument in the middle and closed using a linear stapler with a reinforced bioabsorbable material. This technique was applied to 10 patients with tumours of the caecum, ascending colon, or transverse colon. The median operating time, anastomosis construction time, blood loss, and postoperative stay were 281 min (range 228-459 min), 12 min (range 11-17 min), 10 mL (range 0-110 mL), and 10 days (range 8-15 days), respectively. No adverse intraoperative events were observed. Postoperatively, one patient developed chylous ascites, but there were no other complications. The simple technique for constructing a sutureless overlapped anastomosis using a 60 mm linear stapler with a reinforced bioabsorbable material in robotic right colectomy with intracorporeal anastomosis appears to be safe and feasible.

Risk factors for ischemia/necrosis of the colonic stump after proctectomy and delayed coloanal anastomosis.

Delayed coloanal anastomosis (DCAA) is a two-stage procedure. DCAA has been increasingly reused in recent years in the management of rectal cancer. Such increased use of DCAA has highlighted the complications associated with this procedure. We aimed to evaluate the risk and risk factors of ischemia/necrosis of the colonic stump between the two stages of DCAA. All patients who underwent a proctectomy with a DCAA were included in this retrospective single-centre study from November 2012 to June 2022. Two groups of patients were defined: patients with a well vascularized colonic stump (well vascularized group) and those who experienced ischemia or necrosis of the colonic stump (ischemic group). The primary endpoint was the rate of ischemia or necrosis of the colonic stump and an evaluation of the associated risk factors. During the study period, 43 patients underwent DCAA. Amongst them, 32 (75%) had a well-vascularized colonic stump (well-vascularized group) and 11 (25%) ischemia of the colonic stump (ischemic group). Relative to patients in the well-vascularized group, those in the ischemic group were more often men (81.8% vs 40.6%, p = 0.034), had a higher BMI (29.2kg/m2 vs 25.7kg/m2, p = 0.03), were more frequently diabetic (63.6% vs 21.9%, p = 0.01) and more frequently had had preoperative radiotherapy (100% vs 53.1%, p = 0.008). On the preoperative CT scan, the interspinous diameter was shorter in the ischemic group (9.4 ± 1.01cm vs 10.6 ± 1.01cm, p = 0.001), the intertuberosity diameter was shorter (9.2 ± 1.18cm vs 11.9 ± 1.18cm, p < 0.0001), and the length of the anal canal was longer (31.9 ± 3mm vs 27.4 ± 3.2mm, p < 0.0001). This study highlights clear risk factors for ischemia/necrosis of the colonic stump after proctectomy with DCAA.

'4-Check' protocol for intraoperative anastomotic assessment during transanal total mesorectal excision: retrospective cohort study.

Anastomotic leakage is a major complication following rectal cancer surgery. The primary aim of this study was to investigate the efficacy of a protocol based on a quadruple intraoperative anastomotic assessment (4-Check) during transanal total mesorectal excision (TaTME). Patients who underwent TaTME for rectal cancer with primary anastomosis were reviewed and divided into two groups: before (pre-4-Check: April 2015 - April 2019) and after the implementation of the 4-Check protocol (May 2019 - May 2022). This protocol consisted of a multimodal anastomotic integrity assessment, including indocyanine green-evaluation of colonic stump and intraluminal anastomosis perfusion, a reverse air leak test and anastomotic doughnuts assessment. The primary outcome was incidence of clinical and/or radiological anastomotic leakage. The secondary outcome included intraoperative anastomosis defects and repairs and 30-day complication rate. Propensity score matching and multivariable analyses were performed. Of 186 patients, 160 were selected: 86 patients in the pre-4-Check and 74 in the 4-Check group. After propensity score matching, there was no difference in postoperative anastomotic leakage (pre-4-Check versus 4-Check: 11.1 per cent versus 7.4 per cent; P = 0.50). However, in the 4-Check group, the intraoperative detection of defects and repairs was significantly increased (P = 0.03), and the number of complications was reduced (pre-4-Check versus 4-Check: 33.3 per cent versus 9.3 per cent, P = 0.004). Multivariable analyses confirmed that the use of the 4-Check protocol, the detection of anastomotic defects and increased albumin levels were associated with a reduced number of complications. The 4-Check protocol allowed the intraoperative detection and repair of anastomotic defects. Anastomotic leakage rates were not reduced; however, 30-day complication rates were lower after implementation of this protocol.

V-017 TOTALLY ENDOSCOPIC APPROACH TO MODIFIED SUGARBAKER PARASTOMAL HERNIA REPAIR BY TRANSVERSUS ABDOMINIS RELEASE (ETEP-PAULí). ADVANTAGES OF RETROMUSCULAR/PREPERITONEAL MESH PLACEMENT

Abstract Several studies published have shown that TAR is an effective technique for reconstructing midline hernias and lateral hernias. In 2016, Pauli et al. described a novel technique for parastomal hernioplasty using open TAR combined with a modified Sugarbaker repair.A 56-year-old woman operated on 5 years earlier due to rectum adenocarcinoma by laparoscopic resection. A parastomal hernia was diagnosed. CT revealed a 5 cm wide parastomal hernia associated with an umbilical hernia.Patient is placed in the supine position. Identification by ultrasound of the lateral junction of right rectus sheaths. incision on subcostal region 1 cm medial to said juntion. An incision is made on the anterior lamina and retromuscular space is created with a dissection balloon. With the placement of two 11–5 trocars, the medial aspect of the posterior rectus sheath muscle is incised at the epigastric level and the Crossover is carried out. Left retromuscular dissection is performed. The hernia content is reduced. the left arcuate ligament is identified and the transverse abdominis muscle is released. Anterior defect closure with barded suture. An horizontal peritoneal incision is performed with the aim of lateralizing the colonic stump, the peritoneum and posterior aspect of the rectum sheath are closed.Placement of PPL mesh of 25×30 cms covering the dissected space.Patient was discharged on postoperative day 2. No complications or hernia recurrence were identified. Conclusions This technique offers some advantages; Coated mesh is unnecessary,The retromuscular positioning permits the integration on both sides.However several drawbacks; lack of long-term outcomes and technically challenge.

1037 The Use of Fluorescence Angiography with Indocyanine Green in Colorectal Surgery – A District General Hospital Experience

Abstract Introduction Indocyanine green (ICG) fluorescence imaging is used in a variety of procedures in in colorectal surgery. It optimises intraoperative vision of anatomical structures by improving blood and lymphatic flow. Traditionally, the vascularization of the colonic stump is subjectively evaluated by the surgeon based on the colour of the bowel wall, the bleeding of the colonic stump, and pulsation of the terminal artery. ICG aims to improve objectivity of this assessment. Aim To assess the feasibility and efficacy of ICG in colorectal operations and report on initial experience since introduction in November 2021. Method Retrospective review of prospectively collected database of all patients undergoing colorectal operations with intraoperative ICG use for any indication. Data collected included patient demographic details including age/gender/comorbidities; operative details including indication/type of surgery, 30day-complications, details/outcome of intraoperative ICG use. Results During the study period ten patients underwent colorectal surgical procedures with intra-operative use of ICG. Surgical options included resectional surgery (right hemicolectomy/transverse colectomy/anterior resection) and reconstructive surgery (reversal of hartmann's operation). Majority were done for colorectal cancer and one for inflammatory bowel disease. ICG was reported useful in all cases in demonstrating vascularity in anastomoses/resection margins. One notable case demonstrated decreased ability of discerning ICG uptake in the presence of tattoo pigmentation (preoperative tumour marking). No adverse events were reported. Conclusion The ICG assessment of colonic vascularization was simple, feasible, with no adverse events in our cohort. Our experience suggests caution is required when interpreting ICG readings in the presence of colonic tattoo.

Профилактика осложнений тонко-толстокишечных анастомозов в условиях перитонита

Th e aim of the research. To improve treatment outcomes for patients requiring formation of entero-colonic anastomoses using a new method for prevention of their leakage. Material and methods. A total of 60 patients operated on for peritonitis who potentially required entero-colonic anastomosis were divided into 2 groups. Th e retrospective comparison group included 33 subjects and 27 subjects were enrolled into the prospective main group. Anastomoses for patients in the main group were formed according to the proprietary method that improves blood fl ow along the suture line. Th e method consisted in the following: the leading segment of the small intestine was crossed at an angle of 50-60° to its mesenteric edge. Th e colon stump was also formed by crossing at an angle of 50-60° to its mesenteric edge; a “window” was cut in the antimesenteric part of the colon wall: an oval-shaped area with an area corresponding to the cross-sectional area of the small intestine, the end of the small intestine was connected to the oval hole in the colon “end to side” using a single-row continuous intestinal suture. Primary endpoint: development of leakage in the formed entero-colonic anastomosis. Secondary endpoint: mortality of patients in the postoperative period until discharge from the hospital. Results. Th e proportion of leakage amounted to 3.7% in the main group, and 33.3 % in the comparison group (p=0.007). Th e mortality was 7.4 % and 36.3 %, respectively (p=0.012). Conclusion. The proposed technique for entero-colonic anastomosis formation has advantages due to a signifi cant reduction in the frequency of fistula leakage and mortality

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection.

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR).Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis.Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation.Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art.

Indocyanine green (ICG) fluorescence imaging is widely used in abdominal surgery. The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems. In that setting, ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow. The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery. Each type of use has been separately addressed and the evidence was investigated. During rectal resection, ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks. In addition, ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury. This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed. This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature. Although further studies are need to investigate the real clinical benefits, these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.

Short stump and high anastomosis pull-through (SHiP) procedure for delayed coloanal anastomosis with no protective stoma for low rectal cancer

Despite advances in coloanal anastomosis techniques, satisfactory procedures completed without complications remain lacking. We investigated the effectiveness of our recently developed ‘Short stump and High anastomosis Pull-through’ (SHiP) procedure for delayed coloanal anastomosis without a stoma. In this retrospective study, we analysed functional outcomes, morbidity, and mortality rates and local recurrence of 37 patients treated using SHiP procedure, out of the 282 patients affected by rectal cancer treated in our institution between 2012 and 2020. The inclusion criterion was that the rectal cancer be located within 4 cm from the anal margin. One patient died of local and pulmonary recurrence after 6 years, one developed lung and liver metastases after 2 years, and one experienced local recurrence 2.5 years after surgery. No major leak, retraction, or ischaemia of the colonic stump occurred; the perioperative mortality rate was zero. Five patients (13.51%) had early complications. Stenosis of the anastomosis, which occurred in nine patients (24.3%), was the only long-term complication; only three (8.1%) were symptomatic and were treated with endoscopic dilation. The mean Wexner scores at 24 and 36 months were 8.3 and 8.1 points, respectively. At the 36-month check-up, six patients (24%) had major LARS, ten (40%) had minor LARS, and nine (36%) had no LARS. The functional results in terms of LARS were similar to those previously reported after immediate coloanal anastomosis with protective stoma. The SHiP procedure resulted in a drastic reduction in major complications, and none of the patients had a stoma.

A safe and feasible technique: laparoscopic manual binding technique for intracorporeal anastomosis in totally laparoscopic anterior resection of high-mid rectal cancer.

Totally laparoscopic anterior resection (TLAC) is difficult even for experienced surgeons because of difficulties in fixating the anvil of circular stapling device with laparoscopy. We herein report a novel technique of laparoscopic manual binding technique (MBT) to conduct intracorporeal anastomosis by the double-stapling technique (DST) for high-mid rectal cancer. Since April 2019, MBT for intracorporeal anastomosis in TLAC were performed for 12 patients. After the total mesorectal excision, the anvil of a circular stapling device is put in the abdominal cavity through the anus and inserted into the proximal colonic stump. At the pre-anastomotic site, the intestinal wall of colon is fully fixated on the central rod of the anvil with surgical suture No. 0 by manual binding with laparoscopic instruments as laparoscopic grasping forceps, in addition, double binding if necessary. Then, the end of the colon and rectum is anastomosised by the double-stapling technique (DST). A total of 12 patients completed the operation successfully. Only one patient experienced fever (T < 38.5°C) after operation. No patients experienced surgical complications greater than Clavien-Dindo grade I. We introduced the usefulness of the MBT to improve TLAC. MBT for intracorporeal anastomosis in TLAC for high-mid rectal cancer is safe and feasible.

Hartmann’s operation: 100 years in surgery

The first idea of stage operations for colon cancer was introduced in 1898 by G. F. Ceidler. The first stage of treatment, he recommended the formation of colostoma above the tumor. At the 30th Congress of French Surgeons in 1921 in Strasbourg, H. Hartmann, a surgeon from Paris, reported on the successful treatment of two patients with cancer of the left half of the colon. In the domestic literature, there were different names of Hartmann’s operation. The first report of its performance in our country belongs to N. N. Petrov, who called this intervention operation Coffey – Hartmann (1929) or the single-step intraperitoneal operation by Hartmann (1939). For many decades, the term «obstructive colon resection» has been widely used in foreign and domestic literature. A two-stage operation under this name was developed and practiced by the American surgeon F.W. Rankin in 1928. At the same time, obstructive resection of the colon by Rankin can be performed only in a planned order, unlike Hartmann’s operation, which is carried out also in case of acute colon obstruction. Thus, the following names of surgical interventions using H. Hartmann’s name are valid and terminologically correct: Hartmann’s sigmoid resection (with formation of a flat sigmostoma and suturing of the sigmoid stump); Hartmann’s resection of the sigmoid and rectum (with formation of a flat sigmostoma and suturing of the stump of the supra-ampular or ampular parts of the rectum); left-sided hemicolectomy of Hartmann type (with formation of flat transversostoma and suturing of sigmoid stump); transverse colon resection of Hartmann type (with formation of flat transversostoma and suturing of transverse colon stump).

ICG fluorescence triple check during TaTME

The use of fluorescence angiography has been widespread for almost 50 years, and the use of Indocyanine Green angiography is one of the latest technical evolutions in colorectal surgery. Its application to evaluate the vascular supply of the colon is analyzed in many studies to assess its possible effectiveness to minimize the risk of anastomotic leak. This article describes the ICG fluorescence triple check technique, standardized in a high-volume colorectal center and applied during transanal total mesorectal excision (TaTME) to assess the vascularization of both the colonic stump and the rectal stump before the anastomosis. A last transanal check is performed after the construction of the anastomosis. This technique is now standardized in this center and it could represent a possible application of ICG fluorescence to minimize the risk of anastomotic leak following TaTME.

Correction of Dysbiosis in Diversion Proctitis: Possibilities of Intraluminal Sanitation and the Prevention of Complications after Reconstructive Surgery

Background. Repeated surgical interventions aimed at the colostomy closure and restoration of intestinal continuity after obstructive resections are traumatic and complex reconstructive operations on the colon. The complications of recovery operations largely feature wound abscesses (30–60 %) and anastomotic leakage (5–23 %), with the mortality levels from these complications reaching 0.4–2.8 %. Pronounced dysbiotic changes, the progression of catarrhal or erosive diversion colitis and proctosigmoiditis are the risk factors for anastomotic leakage and postoperative bowel dysfunction. This determines the need for a therapeutic algorithm of intestine sanitation and the introduction of methods for preventing the anastomotic leakage after obstructive resection of the distal colon (Hartmann’s operation). Aim. To evaluate the capability and efficiency of the intraluminal application of rifaximin- α (Alfa Normix ® preparation, Alphasigma company) as a sanitising intestinal antiseptic for relieving diversion colitis and prevening postoperative complications of restorative operations after obstructive resection of the colon (Hartmann’s operation). Material and methods. A prospective comparative controlled study of the results of surgical treatment in 63 patients was conducted. The patients were divided into 2 groups, which were compared using the case-control principle. The operations included the colostomy closure and the restoration of intestinal continuity by applying a colonic anastomosis. In group I (main group, 30 patients), the original “Method of postoperative prevention of colonic anastomotic leakage” (Russian patent No. 2523822) was applied. In the control group (33 patients), routine methods for preventing anastomotic leakage and antibiotic prophylaxis were used. A comparative analysis of the number and severity of purulent-septic complications (taking into account the possibility of their relief), as well as the quality and rate of intestinal dysbiosis relief and the manifestations of diversion proctitis, was carried out. Results. The main group indicated the best results in terms of the main analysed parameters, fewer complications and anastomotic leakage. Thus, the total number of complications in groups I and II was 16.7 % and 27.3 %, respectively. The proportion of complications associated with the anastomotic leakage, inflammatory changes in this area and impaired patency in groups I and II was 6.7 % and 12.1 %, respectively. Rifaximin- α (Alpha Normix ® ) intolerance and pathological reactions associated with its use were not observed. The possibility for effective relief of the violations of quantitative and qualitative composition of the microflora in the colon stump was revealed. The main group showed better results in terms of eliminating local manifestations of diversion colitis and anorectal dysfunction compared to group II, where traditional schemes of postoperative therapy were used. Conclusions. Intraluminal dosed use of the Alpha Normix ® suspension with the rifaximin concentration of 100 mg per 5 ml is an effective method of postoperative prevention of purulent-septic complications associated with anastomotic leakage during reconstructive operations on the distal colon. The introduction of Alpha Normix ® in the scheme of postoperative treatment allows its results to be stabilised due to the sanitation of the intestinal lumen, the elimination of dysbiosis, the relief of inflammatory reaction and the elimination of factors supporting the development of diversion proctitis.

Modification of Turnbull–Cutait transanal colon pull-through as a salvage procedure in cases of failed low colorectal anastomosis

Introduction In 1961, Turnbull and Cutait described the colon pull-through with delayed anastomosis for patients with rectal cancers below peritoneal reflection, Hirschsprung disease, and Chagas disease. With the technological upgrading, the surgical staplers offered an easy and safe primary anastomosis in the bottom of the pelvis and replaced the pull-through. Despite this, the pull-through still has a role nowadays in patients with complex anorectal diseases in whom achieving primary anastomosis is difficult even with the use of surgical staplers. Aim The authors are reporting the experience in Turnbull-Cutait pull-through operation, its indications, the technical modification, and the results. Patients and methods A total of 28 patients had two-stage transanal pull through procedure after completing the original resection for different anorectal problems. In the first stage, the left colon was completely mobilized, pulled through, and fixed to the anal canal, and the perianal skin was done, and covering ileostomy was raised. In the second stage, the pull-through was excised few cm below the anal verge, and the ileostomy was closed. Patients were followed up for 6 months to document the continence status and the development of any complications. Results Autoamputation of the colon stump occurred in 10 patients. Retraction of the pulled colon occurred in five patients causing severe pelvic sepsis in three of them. The three patients were treated by dismantling the anastomosis terminal colostomy. Other minor complications included anal pain and discharge. The patients showed wide range of continence state with clear improvement after 6 months. Conclusion Salvage Turnbull–Cutait pull-through is an easy procedure that can be used in patients with complex anastomotic complications and difficult pelvic anatomy. Retraction and gangrene of the colon stump are serious complications that need to be studied to improve the outcome of this procedure. Continence is definitely reduced, but it is accepted by most patients.

Spectrophotometric assessment of bowel perfusion during low anterior resection: a prospective study

Good perfusion of the bowel and a tension-free anastomosis are the two main prerequisites for an uneventful anastomotic healing in rectal surgery. This prospective cohort study investigates the noninvasive intraoperative spectrophotometric assessment of the bowel perfusion using a device called “Oxygen to See” (O2C®). Forty patients, planned for low anterior resection, were prospectively enrolled in this study to undergo an intraoperative spectrophotometric assessment of the bowel. Three different O2C® parameters were collected from the colonic and the rectal stumps before fashioning the anastomosis: SO2 (capillary venous oxygen saturation), rHb (relative hemoglobin amount), and flow (blood flow velocity). Bowel perfusion was also assessed with the cold-steel-test (CST), which involves severing the colic marginal artery of Drummond at the tip of the colon stump. The data collected from the spectrophotometric measurement and the CST were analyzed for correlation of both methods with respect to each other and to the outcome of the anastomosis. Nine patients were excluded due to different reasons, thus leaving 31 patients for statistical analysis. Three flow parameters collected at the colonic stump significantly predicted an anastomotic leak (p: 0.0057; p: 0.0250; p: 0.0404). One rHb parameter collected at the rectal stump correlated weakly with the anastomotic outcome (p: 0.0768). The CST did not correlate significantly with anastomotic leak (p: 0.1195), but showed significant correlations to some rHb values. Intraoperative noninvasive spectrophotometric measurement is feasible and could be a useful method in assessing bowel perfusion before fashioning a colorectal anastomosis.

1575 Colouterine Fistula: A Rare Crohn's Complication

INTRODUCTION: Colouterine fistulas are a rare complication of gastrointestinal diseases, mostly described as a complication of diverticulitis in elderly patients. Colouterine fistula as a complication of Crohn's disease is exceptionally rare. We present a young Caucasian female with history of poorly controlled Crohn's disease presenting with colouterine fistula. CASE DESCRIPTION/METHODS: 26-year-old Caucasian female with ileal Crohn's disease since 2014 presented with abdominal pain and fever. Her PMH was significant for poor compliance with medications and follow ups. In the preceding 6 months she had a complicated clinical course including a flare with SBO and intraabdominal abscess while she was 23 weeks pregnant needing resection of TI and cecum with a diverting ileostomy followed 2 weeks later by a miscarriage, drainage of a perirectal abscess, fistula between loops of small bowel, and ileostomy take down followed by an abdominal wall abscess needing drainage. She had been lost to follow up and had not been on any medications the preceding one year. Her last colonoscopy was prior to ileostomy take down and had shown healthy appearing ascending colon stump, mild erythematous mucosa throughout the colon with no pathologic evidence of Crohn's and a well healing perianal fistula site. At presentation, ESR was 70 mm/h and CRP 81 mg/L. CT abdomen was read as a large peripherally enhancing fluid collection within the right lower abdomen and pelvis and mildly thickened neoterminal ileum. An abscessogram however showed the fluid collection was a large colouterine fistula filling the ascending colon at the anastomosis and both Fallopian tubes. Patient has been started on induction therapy with adalimumab and discharged with slow prednisone taper with plans to follow up for continued adalimumab therapy as well as evaluation at a facility with specialty Uro-Gynecology resources for fistula correction. DISCUSSION: Fistulas between small bowel and uterus in Crohn's disease has been described in literature. Fistulas between colon and uterus in Crohn's disease is exceptionally rare; to date only two cases have been reported, a sigmoid colouterine fistula and rectouterine fistula. The thick uterine wall is considered to be a protective factor against fistula formation, but prior colonic surgery or disruption of uterine wall integrity may predispose to fistula formation in Crohn's disease. Our patient had a recent ileocecectomy which was likely contributory to colouterine fistulization in the setting of poor compliance.

The first experience of fluorescence laparoscopy for cholecystectomy, the bile ducts and the colon surgery

The aim — to analyse of the first experience with the use of fluorescence laparoscopy (FL) in technically difficult cholecystectomies, revision of the choledochus, lymphodection, colon resection and to assess the blood supply of the anastomosis sites.Materials and methods. Fluorescence laparoscopy was applied in 7 cholecystectomies for acute calculous cholecystitis, 6 common bile duct laparoscopic revisions to estimate the patency (first‑time used technique), laparoscopic right‑side hemicolectomy for estimation the blood supply of anastomosing intestinal areas and open resection of the transverse colon during limfodissections.Results and discussion. In cholecystectomies (fluorescence cholangiography), the duration of the operation and the average time to achieve a «critical type of safety» were reduced to 30 minutes compared with the comparison group (45 minutes). During the intraoperative revision of the choledochus in 1 case of fluorescence in the duodenum was not detected, which showed its obstruction (calculus inclusions). In other cases, the choledochal patency was preserved, which was associated with transient choledocholithiasis. With right‑sided hemicolectomy by fluorescent angiography, adequate blood supply to the colon stump has been proven. With open resection of the transverse colon, fluorescence lymphography was successfully used to visualize the apical lymph nodes at the mouth of the middle colon artery.Conclusions. The first experience showed that fluorescence laparoscopy allows to facilitate and accelerate dissection in case of technically difficult cholecystectomies, to assess the passage of the common bile duct in distinct cases (for example, transient choledocholithiasis), to evaluate the blood supply of the anastomotic sites in colon resections, and to monitor the adequacy of lymph node dissection.