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   Table of Contents - Current issue
October-December 2019
Volume 8 | Issue 4
Page Nos. 89-115

Online since Friday, December 27, 2019

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Abdominosacral resection versus abdominoperineal resection in patients with low rectal carcinoma in terms of exposure/operating time/bleeding p. 89
Rishin Dutta, Sujitesh Saha, Makhan Lal Saha, Abhimanyu Basu, Soumen Das, Dipankar Saha
Background: Comprising nearly 30% of all colorectal cancers, rectal cancer continues to be a significant medical and social problem. Abdominiperineal resection (APR) remains the procedure of choice for patients with rectal carcinoma. An alternative to APR is abdominosacral resection (ASR). Objective: We aim to assess the various modes of presentation, demographic profiles, and histopathological characteristics of tumors, and evaluate the efficacy of ASR over APR in terms of exposure, operating time, bleeding, etc., especially in the perineal/sacral part of the procedure. Design: This was a prospective observational study.Setting: This study was conducted at a superspeciality government hospital in eastern India. Patients and Methods: Patients diagnosed with low rectal carcinoma were included in the study. Two groups were formed using a stratified model of sampling theory; one group underwent APR while the other ASR. Main Outcome Measures: For patients with low rectal cancer, ASR is a feasible approach with reduced bleeding, lesser operating time in the perineal/sacral part of dissection, better exposure, and good oncological outcome.Sample Size: Thirty participants were included in the study. Results: Of the total study participants, 63% were males and 36% females. Patients in their 30s and 40s were the most commonly affected age group. Per-rectal bleeding was the most common presentation. The most common histological tumor encountered was well-differentiated adenocarcinoma. The mean operating time and mean blood loss with regards to the perineal/sacral part of the dissection was less in ASR than that in APR. In addition, the exposure was better in ASR. Ninety-three percent of the patients undergoing ASR had total mesorectal excision. Conclusion: ASR is a feasible approach for low rectal carcinoma and performs better in certain aspects than APR. Limitations: This study had a short duration and included less number of patients. Conflict of Interest: None.
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Transcutaneous posterior tibial nerve stimulation for fecal incontinence: New hope revisited Highly accessed article p. 98
Ahmed A Khalil, Essam F Ebeid, Tarek Y Ahmed, Karim F Elneklawy, Mohamed A Nada
Background: Neuro-modulation of the pelvic nerves is an effective and promising modality for treating fecal incontinence. Direct sacral nerve stimulation is the most popular for neuro-modulation although it is technically demanding. Percutaneous and transcutaneous posterior tibial nerve stimulations are relatively newer approaches for neuro-modulation and they carry the advantage of being cheaper and less invasive. There is not much published data about the transcutaneous approach and in this study, we are describing our experience with this technique. Objective: This study was conducted to describe and determine the efficacy of percutaneous posterior tibial nerve stimulation in the treatment of fecal incontinence. Design: A prospective descriptive study. Setting: The colorectal clinic in the hospital was prepared with the required equipment. The authors funded all procedures performed and the patients paid no extra charges. Patients and Methods: Our study included 15 patients with fecal incontinence visiting the colorectal clinic in Ain Shams University Hospital. All patients received 12 sessions of electric stimulation, 3 sessions per week for 40 minutes each. Main Outcome Measures: Sample Size Wexner score and the short term effect of the treatment. Sample Size: 15 patients. Results: The study included 11 females and 4 males, 2 patients were excluded from the results. The results showed that there was improvement in mean Wexner score for these patients from 13 before the treatment to 8 after finishing the treatment course. Reassessment after 6 months of treatment revealed no deterioration in their continence. Conclusion: We found that transcutaneous posterior tibial nerve stimulation is an effective, cheap, and tolerable method for treating fecal incontinence. However, long-term follow up is required on larger group of patients to adopt this technique. Limitations: Small sample size, short course follow up.Conflict of Interest: None.
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Propofol administration by anesthesiologists versus endoscopists during colonoscopy: Does it make a difference? p. 102
Maher A Abbas, Medhat Shalabi, Denesh Gopalan, Princess Bianzon, Filippos Georgopoulos
Background: Propofol anesthesia for endoscopic procedures has gained wide acceptance among physicians and patients. Much debate remains though whether propofol can be safely administered by non-anesthesiologists. Objective: To compare the procedural outcome of patients undergoing colonoscopy with Propofol target-controlled infusion administered by anesthesiologists vs. non-anesthesiologists. Design: A retrospective review. Setting: A private community hospital in Dubai, United Arab Emirates. Patients and Methods: All consecutive patients (age > 13 years, with American Society of Anesthesiologists class I-II and no other contraindications to administration of sedation by non-anesthesiologists) who underwent colonoscopy between January 1, 2017 and September 30, 2017. In the initial part of the study, propofol was administered by an anesthesiologist until the endoscopists were trained to provide propofol anesthesia via targeted-controlled infusion [TCI] by syringe pump. Intraprocedural data was collected in a prospective registry. Statistical analysis was performed using Chi square and student t test. Main Outcome Measures: Cecal intubation rate, procedural time, procedural-related complications, and polypectomy/biopsy rate. Sample Size: 347 patients. Results: Group 1 [anesthesiologists] 84 patients, Group 2 [endoscopists] 263 patients. Mean age was 44.8 and 46.9 years in Group 1 and 2, respectively (P = 0.17). There was no difference in gender distribution. The mean procedural time was 21 minutes in both groups (P = 0.93). The cecal intubation rate was similar [92.9% in Group 1 vs. 94.3% in Group 2, P = 0.40). No difference in procedural-related complications was noted between groups, with 1 patient in Group 2 sustaining endoscopic perforation during balloon dilation of a near obstructing anastomotic stricture. Except for the patient with endoscopic perforation, no patient required advanced airway management. Conclusions: Propofol can be safely administered by endoscopists using target-controlled infusion. Similar total procedural time and cecal intubation rate can be achieved without increased risk of procedural-related complications. Limitations: Retrospective review, community-based hospital, elective cases, small cohort size. Conflict of Interest: None.
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Submucosal Hemorrhoidectomy versus Hemorrhoidectomy Utilizing an Energy Device in the Treatment of Grade III and IV Hemorrhoidal Disease p. 107
Mohamed S Amar, Mohammed N Nassar
Background: Harmonic scalpel hemorrhoidectomy is associated with lesser pain postoperatively and shorter hospital stays than conventional hemorroidectomy. Objective: To compare the outcome of harmonic scalpel hemorrhoidectomy (HSH) and submucosal ligation hemorrhoidectomy (SLH) in management of Grade III and Grade IV hemorrhoids. Design: A prospective comparative study. Setting: A tertiary hospital was selected. Patients and Methods: This is a prospective randomized study that includes 120 patients with Grade III or Grade IV internal hemorrhoids who were operated in the surgical department of Menoufia University Hospital between February 2016 until December 2018. Main Outcome Measures: Demographic data, perioperative parameters, postoperative complications, and recurrence of hemorrhoids were recorded. All patients were regularly followed up after 1 month, 3 moths, 6 months, and 12 months postoperative for a year. Sample Size: One hundred and twenty patients with Grade III or Grade IV hemorrhoids were divided randomly to SLH (n = 61) and HSH (n = 59) groups. Results: Operative time was 35±12 min in Group A while 18±6 min in Group B with no significant difference between both groups regarding mean hospital stay and time to return to daily activity. Severe pain occurred in 3 cases in Group A while 9 cases in Group B with significantly higher incidence of severe pain in HSH group. The cost was highly significant in HSH group. Anal stenosis occur in 2 (3.2%) cases in Group A and 7 (11.9%) cases in Group B with significantly higher incidence of anal stenosis in HSH group. Conclusion: Both SLH and HSH were safe and effective surgical techniques for management of Grade III and Grade IV hemorrhoids. The SLH technique was associated with less incidence of severe postoperative pain, lower cost, and fewer rate of stenosis. Limitations: Prospective study design, short follow-up period, and learning curve. Conflict of Interest: None.
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Stercoral perforation: A rare entity p. 114
Nisarg Mehta, Ahan Bhatt, Cici Zhang
Stercoral perforation of the colon is a rare condition caused by the pressure necrosis resulting from hard fecaloma, which is commonly found in patients suffering from chronic constipation. Perforations are usually seen in patients afflicted with inflammatory bowel disease, tumor or malignancy, or diverticular disease. Majorly, stercoral perforation affects the elderly and often debilitated patients with a history of chronic constipation. It is a surgical emergency with high mortality, and its prognosis depends on the speed of care. Currently, the pathogenesis of the perforation is not well-defined, but it can likely be a result of long-lasting constipation. If constipation is not treated, stercoral perforation of the large bowel, including the colon and rectum may occur, which is life threatening. Due to constipation, there is an accumulation of feces resulting to large bowel distension that leads to the increase in intraluminal pressure on the walls of the colon, which may result in stercoral perforations. Here, we describe a case of a 60-year-old female who presented with acute symptoms of abdominal distention and pain.
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