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BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes.METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias.RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively.CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

Purpose: Symptomatic hemorrhoids are one of the most common perianal problems with various treatment options. Up to 20% of patients suffering from symptomatic hemorrhoids will require surgery. Excisional Hemorrhoidectomy (EH) and stapled hemorrhoidopexy (SH) are both standard and safe procedures. While SH has a short-term advantage of faster recovery and lower postoperative pain, its long-term efficacy is debatable. The purpose of this study was to compare the long-term outcomes of EH and SH. Methods: This retrospective study compares outcomes of patients who underwent surgical treatment for symptomatic hemorrhoids in our institution during a time period of over 5 years. Eligible patients were contacted by phone and were asked to answer a questionnaire to evaluate recurrent symptoms, fecal incontinence, satisfaction, and quality of life improvement. Results: Three hundred sixty-two patients were included, of whom 215 underwent SH, 99 underwent EH, and 48 underwent a combined procedure. Twenty-three patients (6.3%) suffered postoperative complications or were readmitted. There were no statistically significant differences between the groups regarding rate of complications, symptoms' recurrence, or fecal incontinence. A higher proportion of patients who underwent SH stated they would undergo the surgery again if they had to (p=0.011). There was no difference in quality of life improvement between the groups (p=0.904). Conclusion: Stapled hemorrhoidopexy is non-inferior to hemorrhoidectomy in long-term follow-up regarding patient satisfaction, quality of life improvement, and symptoms' recurrence.

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes. This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage. Fifty-nine patients [43 males, median age was 50 years (range 36–63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4–16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients. ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Postoperative ileus is a common condition following abdominal surgery. Previous studies have shown the positive effects of coffee on gastrointestinal motility. The aim of this study was to assess whether caffeine is the stimulatory agent in coffee that triggers bowel motility and thus may reduce the duration of postoperative ileus. This was a single-centered, prospective, randomized controlled, double-blinded clinical trial. Patients scheduled to undergo elective laparoscopic colectomy between November 2017 and March 2019 were randomly assigned to receive either oral caffeine (100 mg three times daily) or placebo following the procedure. Primary endpoints were time to first flatus and time to first bowel movement. Secondary endpoints were time to tolerate a solid, low-residue diet and length of hospital stay. Registration number: NCT03097900. Seventy patients were included, [35 males, median age 56 years (range 19–79 years)]. After the exclusion of 12 patients, there were 30 patients in the caffeine group and 28 patients in the placebo group. The first passage of stool in the caffeine group occurred 18 h earlier than in the placebo group (p = 0.012); other endpoints did not reach statistical significance. No caffeine-related adverse events were observed. Caffeine consumption following colectomy is safe, leads to a significantly shorter time to first bowel movement, and may thus potentially lead to a shorter postoperative hospital stay.

ObjectivesIntraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: assessing tissue perfusion; identifying/localizing cancer; mapping lymphatic systems; and visualizing anatomy. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging for perfusion assessments using the Idea, Development,Exploration, Assessment, Long Term Study (IDEAL) framework, which was designed for describing the stages of innovation in surgery and other interventional procedures.DesignNarrative literature review with analysis of IDEAL stage of each field of study.SettingAll publications on intraoperative fluorescence imaging for perfusion assessments reported in PubMed through 2019 were identified for six surgical procedures: coronary artery bypass grafting (CABG), upper gastrointestinal (GI) surgery, colorectal surgery, solid organ transplantation, reconstructive surgery, and cerebral aneurysm surgery.Main outcome measuresThe IDEAL stage of research evidence was determined for each specialty field using a previously described approach.Results196 articles (15 003 cases) were selected for analysis. Current status of research evidence was determined to be IDEAL Stage 2a for upper GI and transplantation surgery, IDEAL 2b for CABG, colorectal and cerebral aneurysm surgery, and IDEAL Stage 3 for reconstructive surgery. Using the technique resulted in a high (up to 50%) rate of revisions among surgical procedures, but its efficacy improving postoperative outcomes has not yet been demonstrated by randomized controlled trials in any discipline. Only one possible adverse reaction to intravenous indocyanine green was reported.ConclusionsUsing fluorescence imaging intraoperatively to assess perfusion is feasible and appears useful for surgical decision making across a range of disciplines. Identifying the IDEAL stage of current research knowledge aids in planning further studies to establish the potential for patient benefit.

Constipation is the most common digestive complaint, effecting up to 30% of the population, with considerable healthcare, social, and economic implications. The diagnosis of constipation is often based on the Rome criteria and may be divided into primary constipation and secondary constipation. Primary constipation can be further subdivided into three major categories: normal transit constipation, slow transit constipation, and constipation due to outlet obstruction. This chapter focuses on the definition, epidemiology, and etiology of constipation.

Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.

The incidence of geriatric trauma is rising with an increased life expectancy and a more active lifestyle among the elderly. The aim of this study was to describe the different patterns of injury with increased age in severely injured elderly patients and to identify predictors of in-hospital mortality.

Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported.To present our experience with endovascular management of blunt renal artery injury, and review the literature.We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications.Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered.Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.

The application of a CO2 laser through a flexible fiber for partial nephrectomy produced good parenchymal incision and hemostasis in an animal model., Background and Objectives: Laparoscopic partial nephrectomy (LPN) is a challenging surgery that requires precise tissue cutting and meticulous hemostasis under warm ischemia conditions. In this study, we tested the feasibility of performing LPN using CO2 laser energy transmitted through a specialized flexible mirror optical fiber. Methods: General anesthesia and pneumoperitoneum were induced in 7 farm pigs. Various portions of a kidney, either a pole or a midportion of the kidney, were removed using a novel flexible fiber to transmit CO2 laser energy set at a power of 45W and energy per pulse of 100mJ. The collecting system was approximated with a suture or 2, but no hemostatic measures were taken besides applying a few pulses of the laser to bleeding points. The pigs were sacrificed 3 wk later. Results: Average renal mass removed was 18% of the total kidney weight. All pigs tolerated surgery well. Sharp renal cutting was accomplished in a single continuous incision, with minimal tissue charring and minimal blood loss (

We present the case of an 18-year-old female transferred to our center from an outside hospital due to persistent gastrointestinal bleeding. Two weeks prior to her transfer she underwent duodenal omentopexy for a perforated duodenal peptic ulcer. The patient underwent a computed tomography angiogram which identified the source of bleeding as a giant gastro-duodenal artery (GDA) pseudoaneurysm. The patient was taken to interventional radiology where successful microcoil embolization was performed. We present this rare case of a giant GDA pseudoaneurysm together with imaging and a review of the medical literature regarding prevalence, etiology and treatment options for visceral arterial aneurysms.

BackgroundDue to high prevalence of type 2 diabetes mellitus (T2DM) and increasing popularity of bariatric and metabolic operations, Surgeons are faced with patients with relatively more severe T2DM disease. High level of glycated hemoglobin (HbA1c) is widely considered as a marker for uncontrolled T2DM. The aim of this study was to explore the correlation between high level of pre-operative HbA1c, peri-operative morbidity and post operative outcome after laparoscopic sleeve gastrectomy.MethodsWe conducted a retrospective study based on our medical center metabolic and bariatric registry. The inclusion criteria for selecting patients to the study group was HbA1c of 9 gram/dL and higher. A comparison control study was designed to include T2DM patients similar in all characteristics except for HbA1c of 7.5 gram/dl and less.ResultsWe included 20 patients who underwent laparoscopic sleeve gastrectomy. Each group of patients included half of the patients. The mean pre operative HbA1c in the studied and the control group were 10.4 gram/dL and 7.1 gram/dL respectively (p