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Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer.

Laparoscopy-assisted low anterior resection (LAR) for low rectal cancer is a difficult procedure, presenting problems with rectal washout, selecting the appropriate distal transection line, and achieving safe anastomosis. To resolve these problems, we used a prolapsing technique to perform laparoscopy-assisted LAR. Total mesorectal excision (TME) is performed laparoscopically. The proximal colon is transected laparoscopically with the aid of an endoscopic stapler, and the distal rectum, including the lesion, are everted and pulled transanally to outside the body. Only washout of and wiping off the distal rectum and intestinal resection are performed extracorporeally. The distal rectum is pushed back through the anus into the pelvis, and intracorporeal anastomosis is completed laparoscopically with a double-stapling technique. Our limited experience suggests that the prolapsing technique helps to prevent problems with laparoscopy-assisted LAR in selected patients with low rectal cancer.

Colectomy↗

Nonsurgical Therapy for Solitary Rectal Ulcer Syndrome.

The treatment of solitary rectal ulcer syndrome (SRUS) remains problematic and is less than ideal. Prospective, well-designed studies assessing the efficacy of treatment for SRUS are few; most of the knowledge imparted for treating SRUS is experiential. As such, firm treatment recommendations can not be made. Rather, a conservative, stepwise, individualized approach must be employed. Diagnostic modalities should be incorporated in the management scheme to direct treatment when indicated. Management must include patient reassurance that the underlying lesion is benign, because complete "cures" are uncommon in those with SRUS. The goals of therapy should be discussed with the patient prior to initiating treatment. Although the ultimate goal is macroscopic and microscopic healing, a realistic goal is cessation or minimization of symptoms. We outline a reasonable approach to the management of SRUS. Histologic confirmation of SRUS should prompt a discussion of the presumed pathogenic mechanisms with the patient. Conservative therapy with dietary fiber, bowel retraining, and bulk laxatives should be employed. If symptoms persist, the patient should receive a trial of sucralfate enemas for 6 weeks. Individuals who respond should continue conservative therapy. However, if symptoms persist, defecography can be done to assess for inappropriate puborectalis contraction and occult rectal mucosal prolapse. Patients with inappropriate contraction of the puborectalis can be offered biofeedback. Patients with occult rectal mucosal prolapse can be considered for surgery. However, the risks, benefits, and success rates of surgery should be discussed at length, prior to any procedure being performed. Rectopexy or Delorme's procedure offer the best success rates to date; however, the choice of surgical procedure must take into account the experience of the surgeon and wishes of the patient.

Journal Article↗

[Prevention of post-operative pain and haemorrhage in PPH (Procedure for Prolapse and Hemorrhoids) and STARR (Stapled Trans-Anal Rectal Resection). Preliminary results in 261 cases].

Intra- and early (first week) post-operative haemorrhages are the most common complications in stapled hemorrhoidectomy PPH (Procedure for Prolapse and Hemorrhoids) and in circumferential resection of the rectal prolapse STARR (Stapled Trans Anal Rectal Resection). Performing PPH and STARR we employed a gelatin based haemostatic sealant with thrombin component (FloSeal) to control intra-operative bleeding and to reduce post-operative bleeding avoiding haemostatic stitches on suture line. We report the preliminary results on 197 PPH and 64 STARR; 44 PPH (22.4%) and 27 STARR (42.2%) were treated by FloSeal. No major post-operative bleeding was observed in all patients treated by FloSeal, compared to 1.3% and 2.7% of hemorrhage respectively in PPH and STARR patients treated without sealant. Post-operative pain was less severe in patients treated by FloSeal, without a difference statistically significant. The data are preliminary and must be confirmed in prospective randomized trials in larger series.

Adult↗

Mucosal prolapse syndrome--a unifying concept for solitary ulcer syndrome and related disorders.

Nineteen cases of classical solitary ulcer of the rectum syndrome (SURS) and sixteen examples of rectal mucosal prolapse are described. Similarities in the histological and histochemical features of the two groups lead us to suggest that the term "mucosal prolapse syndrome" be used to describe this group of disorders in which mucosal prolapse--overt or occult is the common underlying pathogenetic mechanism.

Adolescent↗