Aim An anastomotic leak in ileoanal pouch surgery may lead to pouch failure. Constructing a tensionfree ileal pouch-anal anastomosis (IPAA) reduces this risk but can be technically challenging, balancing pouch vascularization with ileal mesenteric length and site of vessel ligation. Fluorescence angiography (FA) may help the clinician make a more balanced judgement.Methods Thirty-two patients undergoing minimally invasive completion proctectomy with FA-guided IPAA at two academic centres were matched and compared on a 1:1 basis to a historical group undergoing the same procedure without the use of this technique.Results Ligation of the ileocolic vessels was safely performed in 15/32 (47%) of FA patients compared with 5/32 (16%) of historical controls. One patient underwent intra-operative IPAA reconstruction after FA detected ischaemia. No anastomotic leak occurred with FA but there was only one in the historical controls (P = 0.31). The postoperative complication rate was similar between the two groups (P = 0.60).Conclusion FA is applicable to IPAA surgery and may help to reduce perfusion-related anastomotic leaks. A prospective randomized trial is warranted.
Duodenal diverticula (DD) are frequently encountered and are usually asymptomatic, with an incidence at autopsy of 22%. Perforation of DD is a rare complication (around 160 cases reported) with potentially dramatic consequences. However, little evidence regarding its treatment is available in the literature. The aim of this study was to review our experience of perforated DD, with a focus on surgical management. Between January 2001 and June 2011, all perforated DD were retrospectively reviewed at a single centre. Seven cases (5 women and 2 men; median age: 72.4 years old, rang: 48-91 years) were found. The median American Society of Anesthesiologists' score in this population was 3 (range: 3-4). The perforation was located in the second portion of duodenum (D2) in six patients and in the third portion (D3) in one patient. Six of these patients were treated surgically: five patients underwent DD resection with direct closure and one was treated by surgical drainage and laparostomy. One patient was treated conservatively. One patient died and one patient presented a leak that was successfully treated conservatively. The median hospital stay was 21.1 d (range: 15-30 d). Perforated DD is an uncommon presentation of a common pathology. Diverticular excision with direct closure seems to offer the best chance of survival and was associated with a low morbidity, even in fragile patients.
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The aetiopathogenesis is multifactorial and patients complaining of it can suffer from both obstructed defaecation syndrome and faecal incontinence. CRP treatments include perineal and abdominal approaches. The choice of approach depends on the age of the patient as well as on the presence of any impairment of anal function but often on the surgeon's experience. To date, neither the PROSPER trial [3] nor recent guidelines [1] have found differences in outcome among abdominal and perineal approaches. Nevertheless, perineal rectosigmoidectomy (the Altemeier procedure) is safe and is the preferred option for unfit patients with CRP. The aim of our video-vignette is to show the different steps of the Altemeier procedure in a 77-year-old woman with CRP and the American Society of Anesthesiologists Physical Status Classification System III. The procedure was performed with the patient in the lithotomy position under spinal anaesthesia (Video S1). An enema and a single dose of cephalosporin plus metronidazole were administered 60 min before the procedure. The postoperative period was uneventful and the patient was discharged 3 days after the procedure with a 5-day oral antibiotics coverage and high-fibre diet plus a recommended oral dose of ketorolac tromethamine 10 mg every 4-6 h, not exceeding 40 mg per day. No persistence of pelvic floor symptoms or recurrence occurred.
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