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   Table of Contents - Current issue
October-December 2020
Volume 9 | Issue 4
Page Nos. 57-72

Online since Thursday, December 31, 2020

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Is Laparoscopic Hartmann's Reversal a Safe Option? A Systematic Review and Meta-Analysis p. 57
Joseph C Kong, Glen R Guerra, Swetha Prabhakaran, Satish K Warrier, Alexander G Heriot
Background: Hartmann's reversal is a major operation to restore colorectal continuity. Traditionally, an open Hartmann's reversal (OHR) has been performed but there is a trend toward performing laparoscopic Hartmann's reversal (LHR). With the increasing number of publications comparing these two, it is important to ascertain whether the benefits of LHR outweigh the risks. Objective: To compare LHR and OHR with respect to morbidity and mortality rates. Design: A systematic review and meta-analysis. Setting: The study was conducted at the Peter MacCallum Cancer Centre in Melbourne, Australia. Patients and Methods: A detailed systematic search was performed through PubMed, SCOPUS, TRIP, EMBASE, and ClinicalKey from 1990 to October 26, 2016. A review was undertaken in accordance with PRISMA guidelines. Main Outcome Measures: The primary outcome measure was 30-day morbidity. Secondary outcome measures included estimated intraoperative blood loss, conversion from laparoscopic to open approach, length of hospital stay, and 30-day mortality. Sample Size: Eighteen eligible studies were identified, comprising a total of 7824 patients: 1586 in the laparoscopic group and 6238 in the open group. Results: There was no statistical difference in mean operative time between the two groups. Overall morbidity was lower in the LHR group (16.8% vs 23.7%, P < 0.0001). Subgroup-analysis showed a higher risk of sepsis (6.5% vs 3.2%; P < 0.0001), wound infection (22.5% vs 12.6%; P < 0.0001), and ileus (13.4% vs 5.5%; P = 0.001) in the OHR group. Conclusion: LHR was associated with a lower morbidity rate and shorter hospital stay with an equivalent operative time. There is a moderate rate of conversion and appropriate case selection is important. Limitations: An absence of prospective or randomized trials comparing the two approaches for Hartmann's reversal, contributing to selection bias in our study. It was difficult to combine patient characteristics data due to the heterogeneity in the reported parameters. Conflict of Interest: None.
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Nigam's Modified Roeder's Knot in Cutting Seton in High Fistula-in-ano Prevents Rethreading and Reapplication of Seton p. 64
VK Nigam, Siddharth Nigam
Background: Fistula-in-ano is known for its recurrence and other complications after surgery, especially in high fistulae cases. Use of a cutting seton is an accepted mode of treatment for high fistula-in-ano cases. Nigam's modified Roeder's knot (NMRK) makes the cutting seton adjustable. The aim of our study is to investigate the results of NMRK application in cutting seton in relation to reapplication, rethreading, postoperative inconvenience to the patient, and postoperative complications. Objectives: To determine whether the NMRK in cutting seton reduces the chances of seton reapplication and postoperative complications in high fistula-in-ano. Design: Squire---Quality Improvement Study. Setting: Patients admitted in various hospitals in Gurugram, Haryana, India. Materials, Methods, and Main Outcome Measures: Eighty high fistula-in-ano patients underwent fistulactomies using the NMRK in both the cutting and adjustable setons between January 2001 and January 2019. Informed consent was obtained from each patient. The patients were evaluated for seton reapplication, inconvenience, recurrence, fecal incontinence, and other postoperative complications. Sample Size: Eighty high fistula-in-ano patients underwent fistulactomies using the NMRK in both the cutting and adjustable setons Results: In our series, no patient suffered fecal incontinence. Three patients (3.75%) had gas incontinence, which gradually stopped within 2 weeks. Most of the setons took 4– 6 weeks to drop. The healing time was 6– 8 weeks for majority of the patients. Two patients (2.50%) developed recurrence after surgery. No patient required readmission or anesthesia for seton reapplication. Conclusion: If the cutting seton with the NMRK is retightened every week, then the drop time of the seton and the total healing time decrease, resulting in reduced incidence of inconvenience, pain, fecal incontinence, and recurrence. Rethreading or reapplication of seton is not required. Limitations: Our study includes only uncomplicated high fistula-in-ano cases. It also excludes complex fistulae, watercan perineum, and fistulae with inflammatory bowel disease or cancer. Conflict of Interest: None. Keywords: Cutting seton, fecal incontinence, fistula-in-ano, Nigam's modified Roeder's knot, recurrence
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Spontaneous Rectal Perforation with Transanal Evisceration p. 68
Maria Sebastian Fuertes, Sonia Martinez Alcaide
We present the case of an 83-year-old woman that visited the emergency room of our hospital for correcting the transanal small bowel evisceration after a defecatory effort, without any history of rectal trauma. Emergency laparotomy was indicated, with the intraoperative finding of perforation in the anterior superior rectum, with a defect of approximately 3 cm. Due to the absence of fecaloid peritonitis, it was decided to perform a primary closure with double sutures. The patient evolved favorably.
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Perforated Toxic Megacolon: The Dreaded Complication in IBD p. 70
Kanmani Murugesu, Premanandan N Sivadasan, Michael Arvind, Wilson Liew Wei Xin
Toxic megacolon is a dreaded complication of inflammatory bowel disease. Unfortunately, it is usually diagnosed late and, in cases of perforation, has a high mortality rate and is associated with a poor prognosis. We present a case of perforated toxic megacolon in a young woman with undiagnosed ulcerative colitis, highlighting the clinical course and outcome of this condition along with the need for prompt detection and intervention. It was difficult to manage this case in a district hospital because of the limited subspecialty support and resources.
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