Dentate Line Research Articles

The repeatability of measurements of male pelvic floor anatomy and function made from transperineal ultrasound images of healthy men and those before and after prostatectomy.

To investigate the inter- and intratester repeatability of measurement of the location and displacement of five pelvic landmarks related to pelvic floor muscles with transperineal ultrasound (TPUS) imaging recorded from healthy men and men before and after prostatectomy. TPUS images were selected from four different participant groups: healthy men, men awaiting prostatectomy, men 2 weeks after prostatectomy, and men 12 months after prostatectomy. On two separate occasions, two assessors with different levels of experience performed analysis of location and displacement of five pelvic landmarks in images made at rest and during voluntary contraction. A two-way mixed effects, single measurement, absolute agreement intraclass correlation coefficient (ICC) was used to investigate the repeatability. Intertester reliability of all locations at rest for all groups was excellent (ICCs > 0.8) except for the craniocaudal coordinate of the ventral urethrovesical junction for men 2 weeks postprostatectomy and the anorectal junction for men with a cancerous prostate. Intertester reliability of the measurement of landmark displacement was acceptable (>0.5) for the dorsoventral axis of motion but not for the craniocaudal axis of motion for all landmarks across all groups. The more experienced assessor was consistently more repeatable. More deeply placed landmarks were more often excluded from analysis and had poorer reliability. Analysis of TPUS images across clinical groups is repeatable for both location and displacement of pelvic landmarks related to pelvic floor muscles when measures are made twice. Analysis experience, landmark depth and optimization of ultrasound settings appear to be important factors in reliability.

Anorectal polyp.

A 71-year-old female with hypertension presented with painless rectal bleeding and found to have a soft mass on rectal exam. The colonoscopy revealed a large pedunculated polyp with patchy discoloration arising from the dentate line (Fig. 1). Biopsies of the polyp were obtained.

Novel approaches to minimize intraoperative bleeding during endoscopic submucosal dissection of a large rectal lateral spreading tumor extended to the dentate line with internal hemorrhoids.

Video 1Endoscopic submucosal dissection (ESD) of large rectal lateral spreading tumors (LSTs) that extend to the dentate line with internal hemorrhoids is a challenging procedure because of the increased risk of bleeding from penetrating and hemorrhoidal vessels and the reduced visual field caused by the dilated venous packages and the narrow anal lumen.This video describes novel technical approaches to minimize the risk of intraoperative bleeding.The described approaches are indicated in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. The described selective-vessel approach is also indicated in any vascularized superficial lesion amenable to endoscopic treatment.ESD was performed in the retroflex view using an Evis Exera II video processor, an H180 gastroscope, an ERBE ICC 200, and CO2 insufflation. As tools, IT-nano, needle knife, hook knife, hemostatic forceps, and a distal cap were used. The lifting solution was a mixture of normal saline, hyaluronic acid, epinephrine, and indigo carmine.A hemicircumferential superficial granular lateral spreading tumor was observed in the lower rectum. Indigo carmine dye spray facilitated the identification of the lesion's margin and demonstrated no ulcer, converging folds, or large nodules. After the submucosal (SM) injection, a shallow mucosal incision was made in the retroflex view using a conventional needle knife, followed by the circumferential incision at the proximal side using an IT-nano. The SM layer was dissected at a superficial level to avoid large SM vessels, thus preventing intraoperative bleeding and maintaining a clean surgical field. Small vessels were selectively coagulated mainly by using the small disc located at the back of the insulated tip as the SM later was superficially dissected. To facilitate precise coagulation, a stepwise dissection technique was used for larger vessels. After identification, the vessel was first exposed by dissecting the surrounding SM layer at the left and right sides using the long blade of IT-nano, with blunt dissection of the surrounding tissue at the vessels' posterior aspect using a Hook knife. Double-vessel sealing using a hemostatic forceps was performed both at the rectal and tumor sides. Lastly, the vessel was transected between sealed segments using the IT-nano, without major bleeding. The circumferential incision was completed at the left side and distally extended to the anal canal where large hemorrhoidal bundles were seen. A needle knife was used to complete the SM dissection and, here, the final cut. En bloc resection was successfully achieved without intraoperative bleeding.The en bloc resected specimen was 85mm in size, and squamous epithelium of the anal canal was observed at the distal margin. Colonoscopy 5 months post-ESD revealed adequate healing, no stenosis and no hemorrhoids.Coagulation and hemostasia should be promptly carried out whenever inadvertent injury to large vessels and subsequent bleeding occurs during lateral exposure, posterior blunt dissection, double coagulation, and transection of vessels.Curative ESD can be achieved in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. Strategies to minimize intraoperative bleeding during ESD should be considered and include the following:•An SM dissection from the proximal tumor margin in the retroflex view to circumvent contact with hemorrhoids.•A differential level of dissection to prevent inadvertent vessel injury-shallow first to avoid large SM vessels and deeper above the muscular layer closer to the dentate line to shut off blood supply by penetrating hemorrhoidal vessels.•Last but not least, a selective approach to vessels to reduce the risk of bleeding, with direct coagulation for small vessels and with lateral exposure, posterior blunt dissection, double-vessel sealing, and transection between sealed segments for larger vessels.

A stem cell population at the anorectal junction maintains homeostasis and participates in tissue regeneration

At numerous locations of the body, transition zones are localized at the crossroad between two types of epithelium and are frequently associated with neoplasia involving both type of tissues. These transition zones contain cells expressing markers of adult stem cells that can be the target of early transformation. The mere fact that transition zone cells can merge different architecture with separate functions implies for a unique plasticity that these cells must display in steady state. However, their roles during tissue regeneration in normal and injured state remain unknown. Here, by using in vivo lineage tracing, single-cell transcriptomics, computational modeling and a three-dimensional organoid culture system of transition zone cells, we identify a population of Krt17+ basal cells with multipotent properties at the squamo-columnar anorectal junction that maintain a squamous epithelium during normal homeostasis and can participate in the repair of a glandular epithelium following tissue injury.

Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial.

The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy. This is a prospective, multicentre, parallel-arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1-3cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group). Twenty-nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra-operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of -1.20% (90% CI -17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI -7.74 to 38.17). Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1-3cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771).

513 PHENOTYPIC CHARACTERIZATION OF FUNCTIONAL DEFECATORY DISORDERS USING SIMULTANEOUS MR DEFECOGRAPHY AND MANOMETRY

BACKGROUND & AIMS High resolution manometry (HRM) is widely used to diagnose defecatory disorders (DD). Contrary to conventional concepts, many healthy people have a negative rectoanal gradient during evacuation (ie, anal > rectal pressure), which undermines our understanding of the mechanisms of normal defecation and DD. Perhaps this is partly because manometry is performed in an empty rectum in the left lateral position. Aimed to better understand the mechanisms of normal defecation and DD, we simultaneously measured rectoanal pressures and evacuation in healthy and constipated women. METHODS We assessed anorectal and abdominal wall motion and rectal evacuation of gel with MR defecography, and pressures with water-perfused manometry in 28 healthy women and 26 women with constipation. Phenotypes were identified by K-means cluster analysis. The unconditional exact test (chi-squared statistic) evaluated the relationship between these clusters and outcomes, ie, balloon expulsion time [BET], subject status (healthy versus constipation) and evacuation. RESULTS Twenty seven participants (19/27 healthy women, 8/26 patients, P 25% of gel). The BET was >60s in 4 controls and 9 patients (P=0.1). The cluster analysis identified 3 distinct clusters, which were defined by pressure and motion variables (Figure 1); BET and rectal evacuation were not variables in the cluster analysis. During evacuation, the rectal pressure, anorectal junction descent, abdominal diameter, and anal diameter were all smaller while the anal canal was longer in cluster 1 (3 evacuators [E], 21 nonevacuators [NE]) (P CONCLUSIONS Manodefecography uncovers 3 clusters in DD. Cluster 1, which predominantly comprises nonevacuators, is characterized by limited abdominal expansion, a spastic pelvic floor, and inadequate rectal pressure during evacuation. By contrast to cluster 1, 24 of 30 (80%) subjects in clusters 2 and 3 were evacuators. In these subjects, abdominal expansion, rectal pressure, and anal opening were preserved; resting anal pressure was lower in cluster 2 than 3. Most patients with DD do not have isolated rectal or anal dysfunctions but rather a combination of impaired abdominal expansion, rectal propulsion, anal opening, and perineal descent during evacuation. Download : Download high-res image (170KB) Download : Download full-size image Figure 1 . The cluster analysis, which was based of 7 variables (Table 1), uncovered 3 distinct clusters. These clusters are plotted using the first two principal components from the 7 variables. The principal component analysis is only used to depict the data; it was not used for the K-means cluster analysis. Cluster 1 predominantly comprises nonevacuators (filled symbols), while clusters 2 and 3 are predominantly evacuators (open symbols). These clusters (1 versus 2 and 3) were associated with evacuator status (P Download : Download high-res image (69KB) Download : Download full-size image Table 1 . Table showing the values of the variables corresponding to centroids of the clusters. During evacuation(e), cluster 1 (3 evacuators[E], 21 nonevacuators [NE]) had lower rectal pressure, anorectal junction descent, abdominal diameter, anal diameter, and a longer anal canal. Cluster 2 (15 E, 4 NE) was characterized by lower anal resting pressure. Compared to clusters 1 and 2, patients in cluster 3 (9 E, 2 NE) had greater anal resting pressure but more anal relaxation during evacuation.

How to Manage the Large Nonpedunculated Colorectal Polyp

How to Manage the Large Nonpedunculated Colorectal Polyp

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

IntroductionSupralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO). MethodsAll consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO. ResultsOut of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%). ConclusionsThe supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

Modified search, coagulation, and clipping with polyglycolic acid sheet and fibrin glue to reduce delayed bleeding risk after endoscopic submucosal dissection near the dentate line.

Modified search, coagulation, and clipping with polyglycolic acid sheet and fibrin glue to reduce delayed bleeding risk after endoscopic submucosal dissection near the dentate line.

The follow-up of the robotic-assisted Soave procedure for Hirschsprung\u2019s disease in children

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to gastrointestinal surgeons. There were many previous reports on robotic technology in performing Soave colonic resection and pull-through for Hirschsprung’s disease in children. This study described the follow-up of the Robotic-assisted Soave procedure for Hirschsprung’s disease in children. Robotic-assisted endorectal pull-through was performed using three robotic arms and an additional 5-mm trocar. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies. The rest of the procedure was carried out according to the Soave procedure. We left a short rectal seromuscular sleeve of 1.5–2 cm above the dentate line. From December 2014 to December 2017, 55 pediatric patients were operated on. Age ranged from 6 months to 10 years old (median = 24.5 months). The aganglionic segment was located in the rectum (n = 38), the sigmoid colon (n = 13), and the left colon (n = 4). The mean total operative time was 93.2 ± 35 min (ranging from 80 to 180 min). Minimal blood was lost during the surgery. During the follow-up period, 41 patients (74.6%) had 1–2 defecations per day, 12 patients (21.8%) had 3–4 defecations per day, and 2 patients (3.6%) had more than 4 defecations per day. Fecal incontinence, enterocolitis, and mild soiling occurred in three (5.4%), four (7.3%), and two pediatric patients, respectively. Robotic-assisted Soave procedure for Hirschsprung’s disease in children is a safe and effective technique. However, a skilled robotic surgical team and procedural modifications are needed.

Encopresis y Diagnóstico tardío de la enfermedad de Hirschsprung, en niño de 7 años

Resumen
 Introducción: La encopresis es la incontinencia fecal repetitiva y espontánea en mayores de 4 años, relacionada con estreñimiento crónico y disfunción de la eliminación del producto fecal, debido a anomalías neurológicas como la ausencia de neuronas entéricas en el colon en la enfermedad de Hirschsprung; a causa de la impactación fecal, el intestino grueso, aumenta tanto de tamaño como de longitud, llamándose Dólico megacolon. El objetivo es presentar el caso clínico de un niño en etapa escolar con encopresis.
 Presentación del caso: Niño de 7 años, acude por incontinencia fecal repetitiva y espontánea asociada a estreñimiento crónico, es diagnosticado por medio de biopsia de la línea pectínea, se reporta presencia de 1-2 células ganglionares y es tratado por enfermedad de Hirschprung. El manejo clínico con dieta blanda, polietilenglicol, agua de zen e irrigaciones rectales, con adherencia deficiente; posteriormente, se realiza exéresis de colon descendente, sigma y recto con técnica de Georgeson, en el postquirúrgico se realizan dilataciones con Hegar 18 y se administra metronidazol 220mg/VO/STAT por complicación postquirúrgica. Tras el manejo clínico y quirúrgico el paciente mejora evacuando 5 veces al día. 
 Conclusión: Se concluye que el tratamiento quirúrgico fue exitoso, sin embargo, el paciente no acude a los controles postquirúrgicos; presentándose nuevamente al servicio, por complicaciones como fisuras anales y rectorragia.

A COMPARATIVE STUDY OF 0.2% NIFEDIPINE VERSUS LATERAL SPHINCTEROTOMY IN THE MANAGEMENT OF ANAL FISSURE

Introduction:Anal ssures are longitudinal tears in the squamous epithelium of the anal canal. Anal ssures are located distal to the dentate line, and in around 90% of cases they are located on the posterior midline. The most common pathologies of the anorectal region and can change the quality of life as it causes patient pain and emotional stress while defecation. With a lifetime risk of 11%, anal ssure is a common problem in routine medical care. Anal ssure is mainly treated by relaxing the spasm of the internal sphincter either by dilating the anal canal or sphincterotomy. Reduction of spasticity of anal sphincters is the special treatment for ssure healing. For this purpose, the treatment of anal ssures is performed by lateral sphincterotomy or by anal dilatation. Methods: Out of 100 randomly selected 50 patients with inclusion and exclusion criteria and informed consent were treated with nifedipine ointment and 50 patients with informed consent were treated with lateral sphincterotomy for management of anal ssure. Observations after treatment were recorded at second week, sixth week and twelfth week interval for bleeding, pain and healing and at the twelfth week follow up was documented to analyse the result of treatment. Result: Out of 50 patients undergoing treatment with Nifedipine ointment 42 patients healed completely. 36 patients in the nifedipine group had complaint of bleeding, after treatment with nifedipine ointment 30 patients were relieved from bleeding while 6 were complaining of bleeding on follow up after 3 months. Patients in lateral sphincterotomy group underwent surgery under spinal anaesthesia. In lateral sphincterotomy group, ssure healing was found in 49 (98%)out of 50 patients. In our study out of 50 patients, 48 (96%)were completely relieved from pain and 2 ( 4% ) had pain on follow up at the end of 3 months. In our study , in the lateral sphincterotomy group 34 patients out of 50 patients were complaining of bleeding and after surgery 32 were relieved from bleeding within 12 weeks and 2 were complaining of bleeding. Conclusion:Topical 2% nifedipine should be given as the rst option of treatment for anal ssure. Lateral sphincterotomy, which gives better result to relieve the symptoms but require hospitalization, should be offered to patient who present with relapse and does not respond to pharmacological treatment.

Anal Fissure - an extensive update.

Anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate line. It causes painful defecation and bleeding per anum. Most of the fissures heal by conservative means but a significant proportion turns chronic, leading to a negative impact upon the overall quality of life of a patient. The treatment options for chronic fissures are generally based on reducing the anal pressures and include non-surgical and surgical modalities. Lateral internal sphincterotomy still remains the gold standard for definitive management of anal fissure though anal incontinence is a serious complication of the procedure. In recent years, various modifications have evolved to minimize chances of incontinence besides the evolution of a wide range of non-surgical options of management. This review outlines the key points in the clinical presentation, etiopathogenesis, impact on the quality of life and management of anal fissure in the light of the recent updates in literature.

Prevalence Rate and Clinical Features of Fissure-in-Ano in a Private Surgical Clinic in Al-Diwaniyah Province, Iraq

Background: One of the most frequent causes of anal discomfort and pain is fissure in ano in which there isa linear tear in the squamous epithelium that lines the anal canal at location distal to dentate line. The diseaseis encountered in both male and female gender and no age is immune particularly middle age and youngage. Little is known about the prevalence rate and clinical presentation in our community of Al-DiwaniyahProvince, Iraq.Aim of the Study: The current study was aiming at identifying the prevalence and clinical Presentation ofFissure-in-Ano in a Private Surgical Clinic in Al-Diwaniyah Province, Iraq.Patients and Method: The current cross sectional study was carried out at a private surgical clinic in AlDiwaniyah Province, Iraq. The study duration extended from January the 2nd 2019 to December the 31st2019.During this period patients with an age between 20-60 years were enrolled based on their clinicalpresentation of an anorectal problem. Any patient with previous anal surgery, with malignant disorder,pregnancy or lactation was excluded from the study. All enrolled patients were examined by digital rectalexamination and proctoscopic examination. Sigmoidoscopy and colonoscopy were done as required.Result: The study included a total of 314 patients with anorectal complaint of whom 78 patients had fissurein ano making the prevalence rate as 24.8 %. Those patients with anal fissure were categorized into 57(73.1%) males and 21 (26.9%) females. Most patients were between 31-40 years of age and the mean ageof all patients was 34.98±7.81 years and the range was 20-60 years. Most of fissures were located in theposterior midline location and the minority of them was seen in an anterior midline location. The majorityof patients had acute disease and the minority of them had chronic disease with some having sentinel pile.Conclusion: It has been shown therefore, that anal fissure is a common problem in our community and thatyoung age and middle age men are the target of majority of cases. The clinical features vary according toage and gender

Robotic taTME using the da Vinci SP: technical notes in a cadaveric model.

Transanal total mesorectal excision (taTME) is an emerging albeit complex technique to treat rectal cancer. The aim of this proof-of-concept preclinical study was to determine the technical feasibility of robotic taTME using the da Vinci SP (dVSP). Two fresh cadavers, one female (case 1) and one male (case2), were used. Focus was given only to the transanal phase of the taTME. Two different clinical scenarios were simulated: in case 1, the tumor was hypothesized to be at 1cm above the anorectal junction; in case 2, at > 4cm. The GelPOINT Path was used as the transanal access platform through which the 2.5cm single port robotic trocar and a 10mm sleeve were inserted. A complete taTME was performed in both cases with a sleeve mucosectomy initiated at the level of the dentate line in case 1. In case 2, the purse-string was created and tightened robotically. At the completion of the procedure, the quality of the mesorectal dissection was verified showing an intact mesorectal fascia in both cases. Operation times were 124 and 106min with a ~ 15min of non-console time for robot positioning and docking. Robotic taTME with the dVSP is technically feasible and might overcome the limits of the traditional laparoscopic approach.

Longitudinal Study of Pelvic Floor Characteristics Before, During, and After Pregnancy in Nulliparous Women.

ObjectivesTo investigate the changes in the pelvic floor before, during, and after pregnancy in the same collective of nulliparous women.MethodsIn a prospective observational pilot study between April 2015 and June 2019 in nulliparous women with planned pregnancy, we used the pelvic organ prolapse quantification (POP‐Q) system; a 2‐dimensional (2D) sonography to investigate the bladder neck, cervix, and anorectal junction positions; and a 3D/4D sonography to measure the hiatus of the levator ani muscle (LH area) during Valsalva maneuver. Five visits were planned: 1 before, 3 during, and 1 visit after pregnancy.ResultsTwenty‐four women participated in the study. We achieved a minimum of 2 visit measurements from 10 women who became pregnant. The LH area decreased during the first trimester and then increased until the third trimester. Postpartum, the LH area reached the prepregnancy state. We observed changes in the bladder neck mobility, bladder neck position, cervix, and anorectal junction from the first trimester. Postpartum, the bladder neck mobility was higher, and the position of the bladder neck and anorectal junction was lower than before pregnancy. We observed no remarkable changes in the POP‐Q state during pregnancy.ConclusionThis was the first study to investigate pelvic floor characteristics in the same collective before, during, and after pregnancy. We observed pelvic floor changes from the prepregnancy state to the first trimester to postpartum. The study results need to be confirmed in a larger study.

Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging.

AimAbdominoperineal resection is associated with poor prognosis in patients with advanced lower rectal cancer. This study aimed to analyse the functional lymphovascular network and tissue drainage in the anorectal region.MethodsIn this descriptive study, we performed microanatomical evaluations and intra‐operative imaging analysis in a cadaver and patients with rectal cancer. Specimens with India ink injection were collected from a cadaver and from six patients who underwent abdominoperineal resection. Intra‐operative indocyanine green fluorescence imaging was performed on four patients who underwent surgery for lower rectal cancer. India ink was injected into the submucosa at the dentate line of specimens. Tissue sections were examined by immunohistochemistry for D2‐40 and CD31. Intra‐operative indocyanine green was injected into the submucosa at the dentate line. Lymph flow was traced using a near‐infrared camera system.ResultsFascia branching from the rectal longitudinal muscle layer extended to the posterior hiatal ligament and lateral endopelvic fascia connective tissue lamina on the surface of the levator ani muscle. The fascia contained veins labelled with ink in their lumina and initial lymphatics. Intra‐operative indocyanine green fluorescence imaging revealed extensive lymph flow from the muscle layer of the anal canal to the hiatal ligament and endopelvic fascia along the longitudinal muscle layer fibres.ConclusionsThe anorectal region contained widespread venous and lymphatic networks in proportion to its specific connective tissue framework around the longitudinal‐muscle‐layer‐extending muscle bundles, which provides extensive networks for tissue fluid and cells.

Surgical technique: an improvisation in application of the technique of core-cut fistulectomy for fistula-in-ano.

Cryptoglandular fistula-in-ano is a chronic inflammatory condition of the perianal region attributed to the obstruction of the glands, located chiefly at the dentate line and their subsequent infection. Anal fistulae are difficult to treat, and minimally invasive procedures are evolving with promises. We present an improvised application of core-cut technique of fistulectomy. It is a minimally invasive, simple, effective and easy to perform procedure with minimal risk of incontinence and recurrence in simple cryptoglandular fistulae-in-ano. We performed 47 cases with good results and present this procedure to emphasize the procedural modification used.

Safety and feasibility of laparoscopic double-flap technique in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction tumors larger than 5 cm

Objective: To investigate the safety and feasibility of laparoscopic double-flap technique (Kamikawa) in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction (EGJ) leiomyoma and gastrointestinal stromal tumor (GIST) with the maximum diameter >5 cm. Methods: A descriptive case-series study was used to retrospectively analyze the data of patients with EGJ leiomyoma and GIST undergoing laparoscopic-assisted proximal gastrectomy and double-flap technique (Kamikawa) at the Department of Gastrointestinal Surgery, Guangdong Hospital of Traditional Chinese Medicine from September 2017 to March 2019. All the tumors invaded the cardia dentate line, and the maximum diameter was >5 cm. After the exclusion of patients requiring emergency surgery and complicating with severe cardiopulmonary diseases, a total of 4 patients, including 3 males and 1 female with age of 29-49 years, were included in this study. After laparoscopic-assisted proximal gastrectomy, the residual stomach was pulled out of the abdominal cavity and marked with methylene blue at the proximal end 3~4 cm from the anterior wall of the residual stomach in the shape of "H". The gastric wall plasma muscular layer was cut along the "H" shape, and the space between the submucosa and the muscular layer was separated to both sides along the longitudinal incision line to make the seromuscular flap. The residual stomach was put back into the abdominal cavity. Under laparoscopy, 4 stitches were intermittently sutured at the upside of "H" shape and 4-5 cm from the posterior wall of the esophageal stump. The stump of the esophagus was cut open, and the submucosa and mucosa were cut under the "H" shape to enter the gastric cavity. The posterior wall of the esophageal stump was sutured continuously with the gastric stump mucosa and submucosa under laparoscopy. The anterior wall of the esophageal stump was sutured continuously with the whole layer of the residual stomach. The anterior wall of the stomach was sutured to cover the esophagus. The anterior gastric muscle flap was sutured and embedded in the esophagus to complete the reconstruction of digestive tract. The morbidity of intraoperative complications and postoperative reflux esophagitis and anastomosis-related complications were observed. Results: All the 4 patients completed the operation successfully, and there was no conversion to laparotomy. The median operative time was 239 (192-261) minutes, the median Kamikawa anastomosis time was 149 (102-163) minutes, and the median intraoperative blood loss was 35 (20-200) ml. The abdominal drainage tube and gastric tube were removed, and the fluid diet was resumed on the first day after surgery in all the 4 patients. The median postoperative hospitalization time was 6 (6-8) days. Postoperative pathology revealed 3 leiomyomas and 1 GIST. There were no postoperative complications such as anastomotic leakage or stenosis, and no reflux symptoms were observed. The median follow-up time was 22 (11-29) months after the operation, and no reflux esophagitis occurred in any of the 4 patients by gastroscopy. Conclusion: For >5 cm EGJ leiomyoma or GIST, double-flap technique (Kamikawa) used for digestive tract reconstruction after proximal gastrectomy is safe and feasible.

Transanterior obturator nerve gateway: a novel approach to achieving intracorporeal distal rectal transection for ultralow rectal cancer.

Intracorporeal rectal transection at the anorectal junction for ultralow rectal cancer is technically difficult due to pelvic width and limited roticulation, which might require a transanal transection or an oblique transection with multiple firings. These procedures were reported to be associated with the increased risk of morbidity. To address these problems, we presented a novel technique Transanterior Obturator Nerve Gateway (TANG) to transect rectum for ultralow rectal cancer and evaluated its safety and feasibility in this study. A total of 210 consecutive patients who underwent laparoscopic coloanal anastomosis with or without partial intersphincteric resection (CAA/pISR) for rectal cancers between January 2017 and January 2020 were included. Eighty of these patients were analyzed using propensity score matching (PSM). The perioperative characteristics, TANG-related variables, and genitourinary and anal function outcomes were analyzed. Among these enrolled patients, 170 patients underwent traditional transection, and 40 underwent TANG transection; the patients were matched to include 40 patients in each group by PSM. After PSM, there were no significant differences in the operating time (p = 0.351) or bleeding volume (p = 0.474) between the two groups. However, the TANG group had fewer cases of conversion to transanal transection (0 vs. 13, p < 0.001). Moreover, the patients in TANG group had a more desirable transection with longer distal resection margin (1.7 vs. 1.1cm, p < 0.001), shorter stapling line (6.6 vs. 10.3cm, p < 0.001) and fewer stapler firings (p < 0.001). The overall postoperative complication rates and genitourinary and anal function outcomes were not significantly different between the two groups. The TANG approach appears to be a safe, feasible and effective approach for intracorporeal ultralow rectal transection with more distal resection, more vertical transection and fewer stapler firings.