Rectal Amputation Research Articles

Pre-Operative Mechanical Bowel Preparation Does Not Affect the Impact of Anastomosis Leakage in Left-Side Colorectal Surgery-A Single Center Observational Study.

Despite rapid advances in colorectal surgery, morbidity and mortality rates in elective gastrointestinal surgery play a significant role. For decades, there have been tempestuous discussions on preventative measures to minimize the risk of anastomotic dehiscence. When mechanical bowel preparation before an elective procedure, one of the key hypotheses, was introduced into practice, it was assumed that it would decrease the number of infectious complications and anastomotic dehiscence. The advancements in antibiotic treatment supported the concomitant administration of oral antibiotics and mechanical bowel preparation. In the prospective study conducted at our clinic, we performed left-side colorectal procedures without prior mechanical preparation. All patients enrolled in the study underwent the surgery and were observed in the 3rd Surgical Clinic, Faculty of Medicine, Comenius University in Bratislava, Slovakia, from January 2019 to January 2020. As a control group, we used a similar group of patients with MBP. Our observed group included 87 patients with tumors in the left part of their large intestine (lineal flexure, descendent colon, sigmoid colon, and rectum). Dixon laparoscopic resection was performed in 26 patients. Sigmoid laparoscopic resection was performed in 27 patients. In 12 patients, the procedure was started laparoscopically but had to be converted due to adverse anatomical conditions. The conservative approaches mostly included Dixon resections (19 patients), sigmoid colon resections (5 patients), left-side hemicolectomies (6 patients), and Miles' tumor resections, with rectal amputation (4 patients). Our study highlighted the fact that MBP does not have an unequivocal benefit for patients with colorectal infection, which has an impact on the development of anastomotic dehiscence.

Coverage of complex pararectal pelvic defects: role of the free myocutaneous musculus vastus lateralis flap

In the event of an advanced rectal carcinoma, an evisceration with rectal amputation may become necessary. The resulting defects, due to their extent, depth, or local tissue damage from previous surgeries and radiation, can in many cases only be closed through free microvascular tissue transfer. In this case series, we demonstrate the successful combination of a musculocutaneous musculus vastus lateralis flap (MVL) with a direct connection to the superior gluteal artery. Over a 47-month period, we retrospectively examined 11 cases of patients with dorsal pelvic defects after evisceration and rectal amputation that could not be closed using local or regional means. In cases of extensive defects with deep pararectal wound cavities, all these patients underwent defect coverage through a free myocutaneous MVL flap with a direct vascular anastomosis to the superior gluteal vessels. The mean defect size was 290.0 cm² (SD: 131.2; range: 200-600 cm²). The mean defect depth was 10.5 cm, necessitating MVL flap reconstruction with an average size of 336.3 cm². Three operative revisions were required due to postoperative bleeding. There were no arterial or venous thromboses, and no flap loss occurred. Only one necrosis of a distal flap tip was observed, which could be corrected secondarily by direct suturing. The case-mix evaluation yielded an average value of 24.251 (SD: 21.699; range: 7.036-65.748) points, emphasizing the complexity of the cases. Our results indicate that a free microvascular MVL flap is a viable therapeutic option for pararectal defects that cannot be closed by local or regional methods. The superior gluteal artery proves to be a safe and sufficient vascular connection. In combination, even extensive defects can be successfully closed.

Two cases of strangulated bowel obstruction due to exposed vessel and nerve after laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer

BackgroundThe majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.Case presentationCase 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.ConclusionAlthough strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.

Squamous cell carcinoma of the anus successfully treated with multidisciplinary therapy for metachronous metastatic and local recurrences after DCF chemotherapy: a case report

BackgroundDocetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy is reportedly an effective treatment strategy for squamous cell carcinoma of the anus (SCCA). However, studies regarding its use in Japanese patients remain scarce.Case presentationHere, we present the case of an 82-year-old woman with SCCA, cStage IIIB. Chemoradiotherapy was initiated after colostomy of the anorectal mass; however, para-aortic lymph node recurrence was observed 3 months after treatment completion. Five courses of DCF chemotherapy were subsequently administered, resulting in a complete response (CR). Two years and 1 month later, the aortic lymph node was enlarged again, and the patient achieved CR again after radiotherapy. Nine months later, local recurrence was detected in the anal canal, and laparoscopic perineal rectal amputation was performed. The patient remains progression-free 5 years and 10 months after the initial treatment and 1 year and 7 months after the final treatment.ConclusionsOur findings suggest that complementary treatment after DCF chemotherapy may be efficacious in Japanese patients with SCCA and help achieve CR. Despite occasional local recurrences, this approach may help achieve long-term progression-free survival.

P753 Early perianal abscess recurrence in patients with perianal Crohn's disease on biologic therapy predicts long-term permanent fecal diversion

Abstract Background Generally, it’s difficult to estimate the efficacy of biologics (Bio) for perianal lesions of Crohn’s disease (CD) and lack of evidence. Sometimes, we experience the recurrence of perianal abscess and need to perform re-drainage even after starting 1st Bio. When the 1st bio fails, choosing an accurate 2nd Bio is difficult. The most severe result of this situation is rectal amputation. We wonder if any relationships between recurrence timing and long-term outcomes exist. We reviewed and aimed to know our institute’s perianal CD (pCD) treatment. Methods We retrospectively investigated patients' medical charts with pCD from 1988 to 2022 at Kenseikai Nara Coloproctology Center. We excluded the patients without using Bio or starting Bio after rectal amputation. The cases with missing values are excluded, too. We defined "early" as within two years and compared two cohorts, the early recurrence group (ER) and the no or late recurrence group (non-ER). We use the Kaplan-Meier method for calculating the time to fecal diversion. Results Eighty patients were recruited. The mean current age is 37.5 years old, and the onset of CD is 22.6 years old. The Perianal lesion’s onset is 24.5 years old. The male is 66, and 19 smokers are included. In this part, perianal lesion means only perianal abscess and fistula. Montreal Classification is shown in TABLE1. The Median follow-up duration was 142.5 months. We performed perianal surveillance (PS) for these patients, including EUA, Abscess Drainage, and seton placement, 3.1 times for each person. After the surgical interventions, we treat them with four Bio. After starting Bio, we experienced 33 early recurrences. We observed eight transient stoma creations, nine rectal amputations, and one anorectal cancer. Among them, we calculate the relationships between early recurrence and rectal amputation and find that early recurrence is a risk factor for permanent fecal diversion (HR 6.84 95%CI 1.48-31.7, p=0.0047 FIGURE1). We needed to switch the Bio for 31 patients during the observational period. To know which way of switching is effective for pCD, we calculate the relationships between the practice of switching and any treatment failure. Same class switching and changing MOA are not different for any treatment failure, which means re-abscess drainage and creation of any stoma (HR 0.40 95%CI 0.10-1.57 p=0.19). Conclusion Perianal abscess recurrence as we need to re-incision and drainage within two years after starting Bio treatment are related to permanent fecal diversion. We must pay attention to such kinds of patients, but the types of Bio we change didn’t affect any treatment failure. Further studies are needed in this field.

Crohn’s disease-related anal fistula cancer diagnosed by examination under anesthesia: a case report

BackgroundAs the number of patients with inflammatory bowel disease (IBD) increases, the incidence of IBD-related colorectal cancer (CRC) is also on the rise. Crohn’s disease (CD)-related CRC has been reported to have a poorer prognosis than sporadic CRC, and the early detection of CD-related CRC is difficult. Japanese patients with CD are reported to have a higher frequency of anorectal cancer than the Western population; however, methods for early diagnosis have not yet been established because of perianal pain during the examination.Case presentationWe report a case of CD-related anal fistula cancer that was detected early by surveillance examination under anesthesia (EUA). The patient was a 37-year-old man, diagnosed with CD at the age of 15 years and started medical treatment. However, due to poor disease control, the intestinal tract remained highly inflamed and the patient continued to have over 10 bowel movements per day. He was referred to our hospital for surgical treatment after a colonoscopy (CS), which revealed multiple active ulcers and stenoses. Since three perianal seton drainage tubes had been placed around his anus since the age of 33 years, we decided to perform an EUA to rule out cancer coexistence in the anorectal region. After a random biopsy of the rectum by CS under general anesthesia, we resected and curetted multiple perianal fistulas as much as possible and reinserted the seton drainage tubes. Pathological examination of the fistula tract revealed adenocarcinoma in one tract, indicating the coexistence of anal fistula cancer. Based on the diagnosis of multiple intestinal stenoses and anal fistula cancer due to CD, we performed hand-assisted laparoscopic total colectomy, rectal amputation, extensive perineal resection, and reconstruction using a left rectus abdominis flap.ConclusionIn a long-term CD patient with anorectal lesions, we performed an EUA to diagnose the coexistence of anal fistula cancer at an early stage, and surgical resection was achieved. EUA is effective for the early detection and treatment of CD-related CRC and may contribute to an improved prognosis.

The Outcome of Rectal Cancer Patients During SARS-CoV-2 Pandemic

Introduction: Rectal cancer is a complex pathology that requires a multidisciplinary approach according to current guidelines, and surgery is one of the main stages of treatment, the type of intervention being established in relation to the location of the tumor at the rectal level. Material and method: The present study aims to analyze the diagnostic features, study the evolution, treatment and complications of patients with rectal cancer in a period marked by the SARS-CoV-2 pandemic. After completing the inclusion criteria, but also the exclusion group, the remaining group consisted of 55 patients with rectal cancer. Results: For the 55 patients, abdominal-pelvic rectal amputation was performed in 17 cases, rectosigmoid resection with colostomy in 13 cases, and rectosigmoid resection with anastomosis in 25 cases. It was also taken into account that the access to medical services was delayed compared to the pre-pandemic period, the increase of the time interval between the treatment stages being an important aspect of the study. Complications associated with surgery have been reported in 13 patients, the most common being the pelvic abscess. Conclusions: The results of the study show a high incidence rate in the age group 60-69 years, with a predominance of males, a delay in making the diagnosis of certainty, an extension of the period from the beginning of neoadjuvant treatment to access to surgery, and the rate of postoperative complications is similar to that described in other studies conducted during the SARS-CoV-2 pandemic, but also outside it.

Stage IV anal canal squamous cell carcinoma with long-term survival: a case report

BackgroundCurrently, no established standard treatment exists for metastatic anal squamous cell carcinoma. We report a case of complete response in a patient with stage IV anal squamous cell carcinoma after undergoing multidisciplinary treatment.Case presentationA 62-year-old woman visited a nearby doctor with a chief concern of severe pain associated with a firm mass in the anus. The patient was diagnosed with anal canal squamous cell carcinoma and liver metastases and referred to First Department of Surgery Faculty of Medicine University of Fukui for treatment. The patient received a TNM classification of T4N0M1 and stage IV. Rectal amputation was performed; however, postoperative complications hindered immediate anticancer therapy and the liver metastases exacerbated. Radiofrequency hyperthermia and systemic chemotherapy were performed 3 months postoperatively. A prominent reduction in the liver metastasis was observed. Lung metastases appeared during the course of systemic chemotherapy. Radiotherapy was performed to treat the lung lesion and resolved. Radiotherapy was also performed for liver metastasis. The lesion in the liver showed resolution after 54 months postoperatively, and treatment with the anticancer drug was discontinued. Ten-year follow-up findings suggested complete resolution of the lesion in response to the treatment protocol followed in this case. This long-term survival was achieved through a multidisciplinary treatment.ConclusionsThe present case suggests that multidisciplinary treatment approach is effective for resolving stage IV anal squamous cell carcinoma, and addition of new anticancer drug therapy may improve the overall prognosis of squamous cell carcinoma.

Displacement of dermal-subcutaneous flaps to close an unhealed wound after abdominoperineal rectal amputation – a case report

Healing of a perineal wound is a very important step in the treatment process after abdominoperineal amputation for rectal cancer. An unhealed wound is a significant clinical problem as it delays the implementation of adjuvant therapy and can become a source of generalised infection. Treatment options include surgical wound debridement and negative pressure therapy, as well as musculocutaneous flap grafting and an inverted gluteal flap techniques. Despite the development of modern therapeutic approaches, difficult-to-heal wounds remain a significant clinical challenge. Some techniques may be ineffective or unfeasible in selected cases. We then go back to traditional surgical techniques. The paper presents a case of treating an unhealed perineal wound by gluteal dermal-subcutaneous flap displacement. In this case, an excellent cosmetic and functional outcome was achieved 30 days after the repair. Traditional surgical techniques, such as the dermal-subcutaneous flap displacement described in this article, are still applicable in the treatment of hard-to-heal wounds after abdominoperineal rectal amputation.

The role of neoadjuvant imatinib in gastrointestinal stromal tumor patients: 20 years of experience from a tertial referral center.

Surgery is the cornerstone of gastrointestinal stromal tumor (GIST) treatment, and adjuvant therapy with imatinib has improved survival for high‐risk tumors. The use of imatinib preoperatively has been increasing, but efficacy and impact on patient outcomes have not been formally investigated. This is a retrospective study from a single‐center cohort of patients diagnosed with GIST and treated with neoadjuvant imatinib at Karolinska University Hospital in Stockholm, Sweden over a 20‐year period. Eighty‐four patients diagnosed with GIST and treated with neoadjuvant imatinib were identified and included. Tumors were located throughout the whole gastrointestinal tract but most frequently in the stomach (n = 29; 35%) and the small intestine (n = 30; 36%), followed by the rectum (n = 12; 14%) and the gastroesophageal junction (n = 10; 12%). The tumors were large (mean 10.5 cm) and decreased after treatment (mean 7.6 cm). Main indications for neoadjuvant imatinib were tumor size or anatomical location. None of the patients with stomach tumors and four patients with tumors near the gastroesophageal junction underwent gastrectomy. Three patients with tumors in the small intestine underwent pancreaticoduodenectomy, whereas seven patients with rectal tumors underwent rectal amputation. After surgery, 94% (n = 79) of the tumors had R0‐resection. About one‐fourth experienced local relapse or distant metastasis. In conclusion, neoadjuvant imatinib can reduce tumor size and prevent high morbidity due to more extensive surgery, or at least reduce the extent of the surgery, especially for tumors in the stomach or small intestine.

Personalized Treatment in Rectal Cancer – a Single Center Study

The study aims to evaluate the incidence, characteristics of diagnosis and treatment for patients with rectal cancer, but also the evolution of patients diagnosed with this neoplasia, so that a personalized treatment can be applied and followed, adapted to the patient’s clinical-imaging picture. The study included 127 patients operated on between January 2018 and November 2021. Dixon resection was performed in 63 patients, rectal amputation (Miles) in 42 patients, and Hartmann resection in 22 patients. For the Miles-type intervention, the patients in a more advanced stage were selected, which represented a percentage of 33.07% of the total. This type of intervention involves a permanent colostomy and has a strong impact on the patient’s life. Of the total of 127 patients, the presence of complications was relatively rare, occurring in only 14 patients. Of the 14 patients, the most common complication was abscess, which occurred in 6 patients, while peritonitis and occlusion occurred in only 4 patients. After analyzing the data obtained, it can be seen that the results coincide with world statistics, the highest incidence of rectal cancer occurring in the age range 60-69 years, with an increased incidence among male patients.

A case of laparoscopic partial hepatic S7 resection for postoperative liver metastasis of rectal malignant melanoma

BackgroundAnorectal malignant melanoma (ARMM) has an extremely poor prognosis, and there is no report of resection of liver metastases so far. We report herein a rare case of postoperative laparoscopic partial hepatic S7 resection for rectal malignant melanoma.Case presentationA 51-year-old female patient with a diagnosis of an ARMM underwent a laparoscopic rectal amputation. Eleven months later, computed tomography (CT) revealed a 14-mm nodule in liver segment 7 (S7), which was diagnosed as a hepatic recurrence of the ARMM. Because no other recurrences were found, a laparoscopic partial resection of S7 was performed. Pathological analysis found intracellular melanin deposition, and immunostaining was S-100 (+), HMB-45 (+), and SOX-10 (+). Based on these findings, a liver metastasis of malignant melanoma was diagnosed. The patient is alive 7 months after the second surgery and has so far experienced no recurrences.ConclusionWe reported an extremely rare case of a laparoscopic resection of a liver metastasis following surgery for ARMM.

Fistulă ileo-perineală: Complicaţie tardivă rară după amputaţia de rect – caz clinic

Abdominal-perineal rectal amputation retains a well-defined place in the surgical treatment of rectal cancer, despite technical advances. The authors present the case of a 67-year-old patient who developed an entero-perineal fistula involving the last ileal loop, two years after an abdominal-perineal rectal amputation for a radiotreated rectal neoplasm. For surgical treatment of the fistula, right ileo-hemicolectomy with ileo-transverse anastomosis were performed. The fistulous tract is treated by soft field typhoon meshing in the same manner of treating the perineal wound after rectal amputation. The evolution is favorable, with the closure of the perineal wound, 6 weeks after surgery. The peculiarity of the case consists in the way of surgical solution. This case presentation is important due to the rarity of the ileo-perineal fistula after amputation of the rectum, as well as due to the particular way of surgical resolution.

Outcomes of surgical treatment in patients with anorectal fistula cancer

BackgroundNo standard treatment for anorectal fistula cancer, such as multidisciplinary therapy, has been established due to the rarity of the disease. Herein, we investigated patients with cancer associated with anorectal fistula who underwent surgery to clarify the clinicopathological characteristics and to propose future perspectives for treatment strategies.Case presentationSeven patients with cancer associated with anorectal fistula who underwent rectal amputation in our institute were analyzed with regard to clinical characteristics, pathological findings, surgical results, and prognosis. Four cases had Crohn's disease as an underlying cause. All seven cases were diagnosed as advanced stage. Preoperative [18F]-fluoro-2-deoxy-d-glucose (FDG)-positron emission tomography/computed tomography (FDG-PET/CT) showed abnormal FDG accumulation in six cases including four mucinous adenocarcinomas. Three cases that received preoperative hyperthermo-chemoradiotherapy achieved pathological R0 resection. Postoperative recurrence was observed in four cases including three with Crohn's disease and one resulting in death.ConclusionsAnorectal fistula cancer is rare and difficult to be diagnosed at early stages. Mucinous adenocarcinoma associated with anorectal fistula tends to exhibit abnormal FDG accumulation by FDG-PET/CT unlike common colorectal mucinous adenocarcinoma. Preoperative hyperthermo-chemoradiotherapy may be effective in obtaining pathological complete resection.

What is the advantage of rectal amputation with an initial perineal approach for primary anorectal carcinoma?

BackgroundRectal amputation (RA) remains an important surgical procedure for salvage despite advances in sphincter-preserving resection, including intersphincteric resection. The aim of this study was to compare short- and long-term outcomes of RA with an initial perineal approach to those of RA with an initial abdominal approach (conventional abdominoperineal resection (APR)) for primary anorectal cancer.MethodsWe retrospectively analyzed the short- and long-term outcomes of 48 patients who underwent RA with an initial perineal approach (perineal group) and 21 patients who underwent RA with an initial abdominal approach (conventional group).ResultsFor the perineal group, the operation time was shorter than that for the conventional group (313 vs. 388 min, p = 0.027). The postoperative complication rate was similar between the two groups (43.8 vs. 47.6%, p = 0.766). Perineal wound complications (PWCs) were significantly fewer in the perineal group than in the conventional group (22.9 vs. 57.1%, p = 0.006). All 69 patients underwent complete TME, but positive CRM was significantly higher in the conventional group than in the perineal group (0 vs. 19.0%, p = 0.011). There were no significant differences in the recurrence (43.8 vs. 47.6%, p = 0.689), 5-year disease-free survival (63.7% vs. 56.7%, p = 0.665) and 5-year overall survival rates (82.5% vs. 66.2%, p = 0.323) between the two groups.ConclusionThese data suggest that RA with an initial perineal approach for selective primary anorectal carcinoma is advantageous in minimizing PWCs and positive CRMs. Further investigations on the advantages of this approach are necessary.

P377 Risk factors of rectal amputation for Crohn’s disease with perianal lesion

Abstract Background Recently, the importance of top-down therapy is emphasised for early Crohn’s Disease (CD). Especially early use of biologics after onset may prevent rectal amputation or permanent stoma concrete of CD with perianal lesion (CDp). The aim of this study was to evaluate the risk factors of permanent stoma concrete for CDp, and especially we had an interest for the relationship between permanent stoma concrete and length of time it takes for infliximab (IFX) was started to use after onset. Methods This is a comparative retrospective study of CDp patients who received IFX therapy at Kenseikai Nara Coloproctology Center between 2002 and 2018. We analysed risk factors of their rectal amputation using logistic regression analysis. Patients were included if they had perianal lesions and received IFX. The cases who received IFX after rectal amputation and who have missing values were excluded. Variables of interest included gender, age at onset and diagnosis, disease duration and location, disease behaviour, smoking, perianal surgical history, timing of IFX use after anoperineal lesion’s onset. Late IFX use was defined as we started to use IFX 2 years after perianal lesion’s onset. Results Fifty-four patients were recruited. Mean age was 37 years old, the ratio of males to females was 3.5. Forty-one patients’ disease was located in the small and large intestine, and thirteen patients’ were located in the large intestine. Median follow-up duration was 149 months. Among 54 patients, 10 patients were received rectal amputation or permanent stoma concrete. The univariate analysis revealed that the risk factors for rectal amputation were smoking habit (OR 7.56, 95% CI 1.41–53.88, p-value = 0.007), penetrating type (OR 6.44, 95% CI 1.21–39.22, p-value = 0.013) and Late IFX use (OR 12.47, 95% CI 1.50–589.26, p = 0.011). A multivariate analysis revealed that smoking habit (OR 21.5, 95% CI 1.92–239, p = 0.013) smoking behaviour (OR 21.5, 95% CI 1.92–239.00, p = 0.013) and Late IFX use (OR 16.0, 95% CI 1.01–254, p = 0.049) were independent risk factor for rectal amputation (Table 1). Conclusion Smoking and late IFX use may be a significant risk factor of rectal amputation for CDp. Early use of biologics may prevent permanent stoma concrete for CDp.

Perineal hernia mesh repair: a fixation with glue, sutures and tacks. How to do it

Introduction: Many different approaches for the repair of a perineal hernia (PH) after abdomino-perineal rectum amputation (APR) have been described throughout the years. Literature shows us that the use of a mesh had the best results with relatively low rates of recurrence compared to primary suture. Yet there is still no consensus on the best technique for fixation of the mesh in the perineal cavity.Methods: We want to introduce an addition to the surgical repair technique, using laparoscopic glue to ensure a solid fixation of the mesh. This is to prevent small bowel from sliding into the perineal area due to the high abdominal pressure when standing and to avoid the difficulties and risks of laparoscopical suturing in this area.Results: This use of glue for fixation of the mesh has been successful in the three cases described, with no recurrence after one-year follow-up.Conclusion: A recurrent PH can be prevented by a solid fixation of the mesh using the technique of a glued mesh repair. This technique shows to be easy, fast and without recurrence.

A rare case of portal pneumatosis. What are the therapeutic resources?

Hepatic portal vein gas was first describes in 1955 by Wolf and Evans. It is a rare and severe condition that in 80% of cases leads to patient’s death. Most common causes are :necrotizing enterocolitis, mesenteric ischemia, sepsis , intestinal perforation. A 73-year old male patient underwent an elective rectal amputation for anal adenocarcinoma, after radiotherapy.In the 12th postoperative day the clinical state of the patient degraded, with onset of acute abdominal pain and fever.A CT scan and ultrasound examination showed the presence of hepatic portal venous gas with of pneumatosis intestinalis and an abcess in the pelvic region.Intraoperatively, two small perforations were found at the distal jejunun with no ischemia or necrosis. An ileostomy was performed, with drainage of the peritoneal cavity.Post-operatively the patient was stabilized and was eventually discharged in stable condition .The presence of hepatic portal venous gas with the of pneumatosis intestinalis is most frequently associated with ischemic bowel, ileus, diverticulitis, gastric distention, inflammatory bowel disease (IBD), hypotension post dialysis treatment, decompression sickness, trauma and iatrogenic causes from instrumentation and recent surgery.

Upotreba autolognih hemoprodukata u mirnodopskim uslovima, vanrednim situacijama i ratu

Introduction In industrialized countries, autologous transfusion (AT) of blood and/or autologous blood products is often used. Objective To perform an analysis on the possibilities of using autologous blood products (ABP) in peace and in war. Methods In peacetime conditions, all AT strategies can be performed: 1) planned preoperative autologous blood and/or blood components collection (PPAB-BCC); 2) acute normovolemic hemodilution (ANH); 3) intraoperative blood salvage of autologous blood; 4) postoperative blood salvage; 5) administration of autologous platelets; 6) the use of autologous fibrin glue and autologous tissue adhesives; 7) the collection and storage of autologous erythrocytes and autologous fresh plasma. In emergency situations and war, the most applicable strategies are: a) ANH; b) intraoperative blood salvage; c) postoperative blood salvage; d) application of autologous fibrin glue and autologous tissue adhesives. Results In peace. PPAB-BCC was used for 314 patients, who were planned for elective surgery. AB was collected using intraoperative blood salvage in the amount of 520 ml for 281 patients. ANH was performed for 30 patients. For 20 of those, 780ml of blood was collected and they were operated on for colon cancer with rectum amputation and one nephrectomy was performed on a patient with single kidney neoplasm. ANH was performed on 9 orthopedic patients. Intraoperative autologous blood salvage in peaceful conditions was performed for 52 adult patients who underwent cardiac surgery procedures. The amount of autologous blood collected and reinfused ranged from 1,500 to 3,500 ml per patient. With the help of a Cell-Saver, autologous blood salvage was performed on 63 patients during pediatric heart surgery. The amount of intraoperative salvaged autologous blood per operation ranged from 210 ml to 620 ml. During the 1990s, doctors at the Military Medical Academy (MMA) used plateletrich autologous plasma on 38 patients who had diseased blood vessels replaced with dacron grafts. In war. During the civil war on the territory of former Yugoslavia, intraoperative salvage of autologous blood was performed on 25 wounded patients who suffered from closed pneumothorax due to blast injury, in which cased 500 ml to 1500 ml of autologous blood was collected. With the help of the 'Pleur-Evac autotransfusion system', immediately after collection, reinfused to the wounded patient during the helicopter transport to the MMA. Autologous fibrin glue was used to treat 10 wounded patients during reconstructive surgery procedures. Conclusion In peacetime conditions, the AT program should be organized in every hospital that has adequate conditions for its implementation. The implementation of AT is very important because it can serve as an alternative to homologous transfusion. Our experiences from the war on the territory of the former Yugoslavia tell us that certain strategies of the AT program can successfully be implemented even in emergency situations and during war.

Laparoscopic Versus Conventional Open Rectum Amputation: a Clinical, Intraoperative, and Short-term Outcome Comparative Study

Abstract Objective: To evaluate and compare laparoscopic and conventional open rectum amputation procedures using clinical, intraoperative, postoperative, and oncological criteria. Methods: Fifty-nine patients with lower rectal and anorectal cancer were included in a retrospective study, conducted between 2014 and 2017. Patients underwent open or laparoscopic rectum amputation surgery and were divided into two groups: group 1 – laparoscopic amputation group (LAG) and group 2 – open amputation group (OAG). The clinical, intraoperative, and postoperative outcomes and oncological results were compared between the two groups. Results: We found a significantly smaller intraoperative blood loss (325 mL vs. 538.29 mL, p = 0.0002), earlier return of bowel motility (2.41 days vs. 3.10 days, p = 0.036), shorter hospital stays (10.08 days vs. 12.66 days, p = 0.03), and a higher number of lymph nodes removed during surgery (12.33 nodes for LAG vs. 9.98 nodes for OAG, p = 0.049). In the open surgery group we found shorter durations of surgery (199.58 minutes for LAG vs. 157.87 minutes for OAG, p = 0.0046). Conclusion: Laparoscopic rectum amputation is a technically demanding procedure. The present study demonstrates the benefits and disadvantages of this surgery, with comparable clinical, intraoperative, postoperative, and oncological results compared to the conventional open rectum amputation procedure.