Despite being a significant cause of morbidity and mortality, colorectal anastomoses are an indisputable gastrointestinal system reconstruction surgery routine. Many patient- and disease-specific factors, including surgical technique, affect anastomotic healing. This study discusses the effects of ketorolac, used for analgesia after colorectal surgery, on the continuity of colorectal anastomoses and intraabdominal adhesions in a rat model. A prospective randomized study was performed at Laboratory of Experimental Animals and Research in the Institute. Thirty Wistar Albino rats were randomized into three equal groups, each consisting of 10 rats. Following rectal transection, end-to-end colorectal anastomosis was performed. During the postoperative period, animals received intramuscular injections of 10 mg/kg isotonic saline, 20 mg/kg meperidine, and 1 mg/kg ketorolac. On the post- operative day seven, the anastomotic segment was resected, and the Nair Score, anastomotic burst pressure, and OH-Proline levels were compared. The OH-Proline values were not statistically significant between the groups (P = 0.566). There was no statistically significant difference between the groups in terms of Nair Scores (P = 0.118). The anastomotic burst pressures of the groups were statistically significantly different (P = 0.017). The anastomotic burst pressures in the group receiving ketorolac were statistically significantly higher than the group receiving meperidine (P = 0.020). In conclusion, this study did not associate perioperative use of ketorolac with anastomotic leakage in the rat model.

Aim: The aim of this study is to evaluate the accuracy of Goodsall’s rule in predicting the internal orifice of perianal fistulas based on magnetic resonance imaging (MRI) findings and to assess its relevance in contemporary imaging and surgical planning. Method: In the retrospective analysis of 1,473 consecutive MRI scans performed for perianal fistulas, a total of 305 patients (men/women: 214/91) with a single fistula were included in the study. Fistulas were classified as anterior or posterior based on the external orifice position relative to the transverse anal line. Results: Posteriorly located fistulas were more common (61.3% vs. 38.7%). The accuracy of Goodsall’s rule was higher in anterior fistulas (64.4%) than in posterior fistulas (39.6%; p<0.001). There was no statistically significant difference in adherence to the rule between genders (p=0.416), different types of fistulas according to the Parks classification (p=0.588), or presence of abscess (p=0.464). Comorbidities significantly affected the accuracy of the rule (p=0.017). In the Bonferroni-adjusted analysis, no significant difference in adherence was found between the cryptoglandular and Crohn’s disease groups (p>0.05). Among the 11 patients with malignancy, only 1 (9.1%) adhered to the rule, indicating reduced accuracy. Conclusion: Goodsall’s rule is more accurate for anterior fistulas; however, it does not apply to all perianal fistula cases, with greater exceptions observed in posterior fistulas. MRI should be considered for all perianal fistulas when possible to improve diagnosis and outcomes.

INTRODUCTION:Intestinal microbiota members, particularly Enterococcus faecalis, play significant roles in the pathogenesis of anastomotic leaks (ALs), with key mechanisms involving collagenase production and matrix metalloproteinase-9 (MMP-9) activation. Diet strongly affects microbiota composition, with Western diets (WDs) promoting dysbiosis, which may exacerbate AL. The effects of mechanical bowel preparation (MBP) and oral antibiotics on AL remain unclear. This experimental study explored the impact of preoperative diet and MBP on AL, focusing on the intestinal microbiota. METHODS:Sixty-four female Wistar albino rats were fed a WD or standard diet (SD) for 3 weeks before surgery. The rats were subsequently divided into subgroups according to MBP or oral antibiotic administration. Enterococcus colonies were analyzed throughout the procedure, and their correlation with AL was evaluated by assessing collagenase activity and MMP-9 tissue concentrations. RESULTS:Enterococcus colony collagenase activity was significantly greater in the WD group than in the SD group (P = 0.024). Moreover, anastomotic burst pressures were nonsignificantly lower in the WD group. Finally, MMP-9 levels and collagenase activity were significantly lower in the groups that received either diet with oral antibiotics and MBP than in other subgroups (P = 0.045 and P = 0.007, respectively). CONCLUSIONS:An SD, especially combined with MBP and oral antibiotics, plays a critical role in reducing the risk of AL by modulating collagenase activity in E faecalis and MMP-9 tissue concentrations in rats. Thus, dietary interventions may improve surgical outcomes; however, further clinical studies are necessary to validate these results in human populations.

PurposeSacrococcygeal pilonidal disease (SPD) is a global concern, notably in Southeast Europe and the Middle East. Unroofing curettage (UC), which provides faster recovery, better cosmetic appearance, and lower recurrence rates in the primary cases, was evaluated with the results of recurrent disease.MethodsThis retrospective study included 74 patients with recurrent disease who were over 16 years of age, experienced recurrence after at least one surgical attempt, and underwent unroofing curettage between 2007 and 2019. Operation time, return to work duration, and recurrence rates were assessed.ResultsMean age of patients was 29.8 ± 10.6 years, and 61 (82.4%) were male. Previous procedures included excision + flap reconstruction, excision + primary closure, and local excision + lay open. Mean operation time for unroofing curettage was 22 ± 5.3 min. Mean durations for return to work and recovery were 5.9 ± 3 days, and 6.5 ± 2.6 weeks, respectively. Mean follow-up duration was 81.6 ± 49 months. Recurrence was only observed in 1 (1.3%) patient. Unroofing curettage showed a mean recurrence-free period of 156.9 months (95% CI [, 152.9–160.9 months).ConclusionUnroofing curettage stands out as a low-recurrence approach, likely to persist as a treatment method, especially for a selected group with recurrence.

Aim: Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. Method: COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Results: Some 725 patients (median age 68.0years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] =1.56, 95% CI: 0.48-5.02, p=0.457) or earlier detection (hazard ratio [HR] =1.07, 95% CI: 0.61-1.90, p=0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR=1.26, 95% CI: 0.67-2.36, p=0.478), delayed hospital discharge (HR=1.11, 95% CI: 0.91-1.36, p=0.303) or increased risk of SSIs (OR=1.61, 95% CI: 0.87-2.99, p=0.128). Conclusion: This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Long-term bowel dysfunction after resection for rectal cancer, known as low anterior resection syndrome (LARS), is observed in many patients. The LARS score was developed to assess this syndrome and its impact on the quality of life in Danish patients. Recently versions in English and many other languages have been validated. The aim of this study was to validate the Turkish translation of the LARS score in patients who have undergone treatment for rectal cancer. Rectal cancer patients who underwent low anterior resection in May 2000- May 2018 in three Turkish centers received the LARS score questionnaire, the European Organisation for Research and Treatment Of Cancer Core Quality of Life questionnaire [Ed.11] (EORTC QLQ-C30), and a single ad hoc quality of life question. The test–retest reliability of the LARS score was evaluated by asking a randomly selected subgroup of patients to repeat the assessment of the LARS score 2 to 4 weeks after their initial response. A total of 326 patients were reviewed and contacted for the study, and 222 (68

AIM:Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours. METHOD:This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated. RESULTS:One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours. CONCLUSION:Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

Objectives:To analyze the change in circulating angiogenic factor levels after transarterial radioembolization (TARE) for colorectal cancer liver metastases (CRCLMs) and its prognostic significance.Methods:Blood samples immediately before TARE and on 1 day, 1 week and 6 weeks after were collected for angiogenic factor analysis in 23 patients.Results:Patients with elevated serum basic fibroblast growth factor and platelet-derived growth factor levels in the 1st week and vascular endothelial growth factor (VEGF) levels in the 6th week after TARE had significantly shorter median overall survival (OS) times.Conclusion:Some early increases in serum angiogenic factor levels and in serum VEGF in the 6th week after TARE for CRCLMs are related to short OS and progression-free survival.

BACKGROUND Since December 2019, the COVID-19 pandemic has created an increasing challenge in managing inflammatory bowel disease patients both medically and surgically. Although several international and national medical/surgical associations published guidelines in this area, there is still a huge difference between daily practices and these guidelines, especially depending on regional practices and governmental policies. Therefore, we aimed to investigate and define gastroenterologists' and surgeons' fear of COVID-19 and how they have managed inflammatory bowel disease patients during this pandemic in the Black Sea region. METHODS A 20-question survey was administered to 70 gastroenterology specialists and 80 general surgeons who are mainly focused on the management of inflammatory bowel disease in 5 countries in the Black Sea region. RESULTS The majority of respondents (81.3%) mentioned that they have concerns that their inflammatory bowel disease patients were at risk of contracting COVID-19. In addition, the majority of respondents (80.3%) believed that inflammatory bowel disease itself, independent of medications, might increase the risk of contracting COVID-19. The majority of gastroenterologists told that they did not stop inflammatory bowel disease medications due to the COVID-19 pandemic unless patients had COVID-19 disease. Surgeons overwhelmingly reached a consensus on how to test patients for COVID-19 perioperatively and came to a conclusion on which of the patients cannot wait to be operated. Both gastroenterologists and general surgeons, usually have similar perceptions. CONCLUSION Despite the increasing number of definitive studies, it seems that there are still regional differences in the perception of COVID-19 and inflammatory bowel disease patient care during the pandemic.

For the fistuli that we cannot do fistulotomy, there were several surgical techniques described. Ligation of the intersphincteric fistula tract is one of these methods especially for low-laid trans-sphincteric fistuli in low BMI patients. In this chapter, the technique and results of LIFT procedure are discussed.

Surgical treatment for low rectal cancer has changed dramatically during the preceding several decades, and the optimal surgical approach remains incompletely developed. Transanal total mesorectal excision is likely the most promising approach for the dissection of the distal part of the mesorectum in a manner that allows for a technically easy and oncologically safe operation. Long after it was first described, the Turnbull–Cutait abdominoperineal pull-through procedure has recently been reintroduced in surgical practice for the treatment of patients with complex anorectal conditions. The current report describes a case of distal rectal cancer involving successful surgical treatment with a combination of the two aforementioned methods and patient discharge without a diverting stoma.

Abstract Objective To prospectively assess the construct and criterion validity of ClassIntra version 1.0, a newly developed classification for assessing intraoperative adverse events. Design International, multicentre cohort study. Setting 18 secondary and tertiary centres from 12 countries in Europe, Oceania, and North America. Participants The cohort study included a representative sample of 2520 patients in hospital having any type of surgery, followed up until discharge. A follow-up to assess mortality at 30 days was performed in 2372 patients (94%). A survey was sent to a representative sample of 163 surgeons and anaesthetists from participating centres. Main outcome measures Intraoperative complications were assessed according to ClassIntra. Postoperative complications were assessed daily until discharge from hospital with the Clavien-Dindo classification. The primary endpoint was construct validity by investigating the risk adjusted association between the most severe intraoperative and postoperative complications, measured in a multivariable hierarchical proportional odds model. For criterion validity, inter-rater reliability was evaluated in a survey of 10 fictitious case scenarios describing intraoperative complications. Results Of 2520 patients enrolled, 610 (24%) experienced at least one intraoperative adverse event and 838 (33%) at least one postoperative complication. Multivariable analysis showed a gradual increase in risk for a more severe postoperative complication with increasing grade of ClassIntra: ClassIntra grade I versus grade 0, odds ratio 0.99 (95% confidence interval 0.69 to 1.42); grade II versus grade 0, 1.39 (0.97 to 2.00); grade III versus grade 0, 2.62 (1.31 to 5.26); and grade IV versus grade 0, 3.81 (1.19 to 12.2). ClassIntra showed high criterion validity with an intraclass correlation coefficient of 0.76 (95% confidence interval 0.59 to 0.91) in the survey (response rate 83%). Conclusions ClassIntra is the first prospectively validated classification for assessing intraoperative adverse events in a standardised way, linking them to postoperative complications with the well established Clavien-Dindo classification. ClassIntra can be incorporated into routine practice in perioperative surgical safety checklists, or used as a monitoring and outcome reporting tool for different surgical disciplines. Future studies should investigate whether the tool is useful to stratify patients to the appropriate postoperative care, to enhance the quality of surgical interventions, and to improve long term outcomes of surgical patients. Trial registration ClinicalTrials.gov NCT03009929.

Osteomas are well-differentiated, slowly-growing and asymptomatic benign tumors of mature bone. Osteomas are usually observed on the jaw and classified into two types as central and peripheral osteoma. Diagnosis is made by observing radio-opacities on computed tomography. While follow-up is recommended for minor cases, surgical excision should be performed for major cases. Gardner syndrome is an autosomal dominant disease characterized by intestinal polyps and multiple osteomas. Due to the malignancy potential of intestinal polyps, early diagnosis and treatment are important. In this case report, diagnosis, surgical treatment and two years follow-up of a patient with Gardner syndrome are presented.

Rectal lesions, benign or malignant, are one of the most encountered clinical entities in general surgery departments. Technological breakthroughs in local excision techniques have been occurring such as transanal endoscopic microsurgery (TEM), transanal minimally invasive surgery (TAMIS), and transanal endoscopic operations (TEO) during the last two decades. We compared the results between TAMIS and TEO for removing rectal lesions. The study was conducted on patients who underwent TAMIS and TEO interventions due to rectal lesions between 2010 and 2015 in the Department of General Surgery of Gulhane Military Medical Academy and the University of Ankara. The data for these patients relating to their age, gender, distance from the anal verge, operation time, occurrence of first bowel movement after surgery, initiation of oral intake after surgery, length of hospital stay, tumor size, follow-up, complications, free resection margin, recurrence, postoperative Fecal Incontinence Severity Index (FISI) and visual analog scale (VAS) scores, and pathologic specimen examination were taken from the hospital's electronic database. All data were enrolled and analyzed statistically. The TAMIS group had 23 (54.8%) patients, and the TEO group had 19 (45.2%) patients. The TAMIS operation time was significantly longer than that of TEO (Z = 3.188;P < 0.001). Median time to first bowel movement in the TAMIS group was 36.0 h (interquartile range (IQR) = 12.0) vs. 24.0 h (IQR = 18.0) in the TEO group; the difference was significant (Z = 3.358;P = 0.001). No significant differences were found between the two groups in complication rate, recurrence, visual analog scale, or Fecal Incontinence Severity Index. TAMIS and TEO techniques have been found to produce almost similar results. These two techniques are considered to be good alternatives to conservative treatment methods with their reliability and feasibility in experienced hands for selected patients. For TAMIS and TEO techniques to qualify as "treatment of choice," prospective randomized clinical trials are needed.

Willem A. Bemelman,a Janindra Warusavitarne,b Gianluca M. Sampietro,c Zuzana Serclova,d Oded Zmora,e Gaetano Luglio,f Anthony de Buck van Overstraeten,g John P. Burke,h Christianne J. Buskens,a Francesco Colombo,c Jorge Amil Dias,i Rami Eliakim,j Tomás Elosua,k I. Ethem Gecim,l Sanja Kolacek,m Jaroslaw Kierkus,n Kaija-Leena Kolho,o Jérémie H. Lefevre,p Monica Millan,q Yves Panis,r Thomas Pinkney,s Richard K. Russell,t Chaya Shwaartz,u Carolynne Vaizey,b Nuha Yassin,v André D’Hooreg; on behalf of the European Crohn’s and Colitis Organisation [ECCO] and the European Society of Colo-Proctology [ESCP]

Colorectal DiseaseVolume 20, Issue 10 p. O286-O287 ESCP ESCP President's Report E. Gecim, E. Gecim Professor of Surgery, Ankara University Medical School, Turkey gecimethem@gmail.com Search for more papers by this author E. Gecim, E. Gecim Professor of Surgery, Ankara University Medical School, Turkey gecimethem@gmail.com Search for more papers by this author First published: 01 October 2018 https://doi.org/10.1111/codi.14401Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume20, Issue10October 2018Pages O286-O287 RelatedInformation

AimThe management of postoperative ileus following colorectal surgery remains controversial. It is the commonest complication after elective colorectal resection and is associated with an increased incidence of postoperative adverse events. The prevention and management of postoperative ileus remains unstandardized. This study aims to describe an international profile of gastrointestinal recovery after colorectal surgery and will assess the role of non-steroidal anti-inflammatory drugs, when used as postoperative analgesia, in expediting the return of gastrointestinal function. MethodsA multicentre, student- and trainee-led, prospective cohort study will be conducted across both Europe and Australasia. Adult patients undergoing elective colorectal resection during 2-week data collection periods between January and April 2018 will be included. A site-specific questionnaire will capture compliance to Enhanced Recovery after Surgery components at participating centres. The primary outcome is time to gastrointestinal recovery, measured using a composite outcome of bowel function and oral tolerance. The impact of non-steroidal anti-inflammatory drugs on gastrointestinal recovery will be evaluated along with safety data with respect to anastomotic leak, acute kidney injury and complications within 30days of surgery. DiscussionThis protocol describes the methodology of an international, observational assessment of gastrointestinal recovery after colorectal surgery. It discusses key challenges and describes how the results will impact on future investigation. The study will be conducted across a large student- and trainee-led collaborative network, with prospective quality assurance and data validation strategies.

OBJECTIVETo determine the diagnostic value of 3 Tesla MR imaging in detection of mucosal (Tis), submucosal (T1) and muscularis propria (T2) invasion in patients with early rectal cancer.METHODSA total of 50 consecutive patients who underwent 3 Tesla MR imaging and curative-intent intervention for MRI-staged Tis/T1/T2 rectal cancer from March 2012 to December 2016 were included. The radiological T category of each rectal tumour was compared retrospectively with histopathological results assessed according to the tumor, node, metastasis (TNM) classification. The sensitivities, specificities, and overall accuracy rates of 3 Tesla MR imaging for Tis, T1, and T2 cases were calculated using MedCalc statistical software v. 16.RESULTSThe sensitivity, specificity, PPV, NPV of 3 Tesla MR imaging in T categorization for T2 were: 93.7% [95% CI (0.79-0.99)], 77.7% [95% CI (0.52-0.93)], 88.2% [95% CI (0.75-0.94)] and 87.5% [95% CI (0.64-0.96)]; for T1 were 92% [95% CI (0.63-0.99)], 91.8% [95% CI (0.78-0.98)], 80% [95% CI (0.57-0.92)] and 97.1% [95% CI (0.83-0.99)]; for Tis were: 20% [95% CI (0.51-0.71)], 100% [95% CI (0.92-1)], 100%, 91.8% [95% CI (0.87-0.94)], respectively. MR categorization accuracy rates for T2, T1 and Tis were calculated as 88, 92 and 92%, respectively.CONCLUSION3 Tesla MR imaging seems to be useful for accurate categorization of T-stage in early rectal cancer, especially for T1 cancers. The method is not a reliable tool to detect Tis cases. The potential for overstaging and understaging of the technique should be realized and taken into consideration when tailoring the treatment protocol for each patient. Advances in knowledge: High-resolution MR with phased-array coil is being increasingly used in the pre-operative assessment of rectal cancer. 3 Tesla high-resolution MR imaging allows improved definition of bowel wall and tumour infiltration.

BACKGROUND:No single treatment yet exists for pilonidal disease that has a short healing time, good cosmetic results, and a low rate of recurrence. Phenol crystal application and diathermy ablation through an endoscope have been used for the treatment of pilonidal disease, but this cohort is the first one to combine them.OBJECTIVE:The purpose of this study was to examine the safety, effectiveness, and short- and long-term outcomes of crystalized phenol treatment combined with endoscopic pilonidal sinus treatment for pilonidal disease.DESIGN:This was a prospective cohort study.SETTINGS:Procedures were performed in 2 hospitals by the same surgeon between February and July 2014.PATIENTS:Twenty-three patients underwent surgical treatment for pilonidal disease.INTERVENTIONS:Under local anesthesia and sedation, all of the patients underwent a video-assisted diathermy ablation of the sinus cavity and the application of phenol crystals.MAIN OUTCOME MEASURES:Adverse events were recorded as a measure of safety and tolerability. Failure to heal and recurrence rate were documented and evaluated.RESULTS:Patients were discharged on the same day as surgery. There was no or minimal postoperative pain (mean visual analog scale score, 1.40 ± 0.95). Mean operation time was 20.43 ± 6.19 minutes, and the median return-to-work duration was 2.00 days (mean, 3.03 ± 2.95 d). Patients were followed-up for 18 to 24 months (mean, 22.00 ± 1.88 mo). No serious complications or rehospitalization were observed. No primary failure to heal or recurrence was observed.LIMITATIONS:This study did not include a control group with which to compare and consisted of a relatively small number of patients.CONCLUSIONS:Crystalized phenol treatment combined with endoscopic pilonidal sinus treatment was safe, tolerable, and achieved fast and durable healing with no recurrence over an average of 22 months of follow-up.