RATIONALE/OBJECTIVES: The Turnbull-Cutait transanal pullthrough procedure with delayed coloanal anastomosis has been widely used before the advent of intestinal stapling devices. It is a viable option for rectal reconstruction for benign and malignant conditions, and is able to maintain intestinal continuity without the use of a temporary diversion. It has also been used in salvage operations for pelvic sepsis, failed anastomosis, and tumor recurrence that will otherwise require a permanent ileostomy. This study will describe the technique, as well as the outcomes of patients who underwent the procedure. METHODS: This is a retrospective descriptive study conducted to report the outcomes of patients who underwent the Turnbull-Cutait transanal pull-through with delayed coloanal anastomosis at the Philippine General Hospital from January 2008 to December 2013. Eleven patients were identified using an institutional retrospective database. Clinical data and outcomes were collected using a standard form. RESULTS: Ten of the 11 patients had an unremarkable postoperative course. One patient had an anastomotic dehiscence. The mean operative time was 229.9 minutes for the 1st stage and 28.2 minutes for the second stage, with a mean blood loss of 463.6 cc for both stages. The mean interval between the two stages was 7.9 days, with an average postoperative length of stay of 8.27 days. The average follow-up was 4.5 years. Functional outcomes were acceptable (average Wexner score 5.63), except for one patient who had an anastomotic dehiscence. No perioperative mortality was noted. CONCLUSION Turnbull-Cutait trans-anal pullthrough procedure with delayed coloanal anastomosis appears to be a safe procedure. The study suggests that it is an alternative strategy in rectal cancer in providing a sphincter-saving surgery, with the establishment of gastrointestinal continuity, and without the need for a proximal diversion. Stoma-less surgery has a notable health economic impact especially in developing countries because it eliminates the costs associated with the use of stoma appliances.

BACKGROUND: Hirschsprung’s disease (HD) is rare in adults, since a majority of cases are corrected in childhood. OBJECTIVES: The authors describe the profile of patients with HD who reached adulthood without having undergone corrective surgery. Also, they describe the outcomes of a modified Duhamel procedure in these patients, in terms of morbidity and mortality. METHODS: This retrospective study, included patients 18 years old and above, diagnosed with HD who reached adulthood without having undergone definitive repair and managed surgically by the Division of Colorectal Surgery, UP-PGH from January 1, 2004 to December 31, 2014. A review from the Department Surgical Database was used and patients’ hospital records were used to fill out a Data Collection Form. Descriptive statistics were used to summarize the data. RESULTS: The 13 patients included in the study were diagnosed at an average age of 16.6 (± 13.16) years. The mean age at the time of definitive surgery was 23.46 (± 6.96) years. The M:F ratio was 5.5:1. The most common presenting symptom was constipation (69.23%). All had a prior proximal bowel diversion, with a transverse loop colostomy (61.54%) being the most common. The transition zone was located in the sigmoid in a third of patients. The mean time from diagnosis to definitive surgery was 6.69 years. Eight (61.54%) have since undergone stoma reversal. There was only one (7.69%) morbidity, a superficial surgical site infection. No mortalities were reported. CONCLUSION The modified Duhamel procedure is a safe definitive surgical procedure for the adult patient with HD.

Buschke-Lowenstein tumor (BLT) is a sexually transmitted infection (STI) caused by the human papillomavirus. This study investigated the profile, management, and outcomes of patients who underwent surgery for BLT from 2015 to 2019 at the Philippine General Hospital. Seven patients underwent surgery for BLT. All were male, with ages ranging from 21 to 41 years. Presenting symptoms were anal mass, foul-smelling discharge, pain, bleeding, and pruritus. All were positive for human immunodeficiency virus. All admitted to having engaged in both insertive and receptive anal intercourse, with multiple partners. All underwent excision with healing by secondary intention. Two had recurrence of warts. Four had an anal stricture. Of these, 3 underwent anal dilatation, while 1 had to undergo proximal bowel diversion. One had intraepithelial carcinoma without dermal invasion on histopathologic analysis. BLT is a rare STI characterized by local aggressiveness but with low malignant potential. Wide excision remains to be the mainstay of treatment.

McKittrick-Wheelock syndrome is a rare and life-threatening disease characterized by the triad of (1) chronic mucous diarrhea, (2) renal function impairment with hydroelectrolyte imbalance, and (3) a giant colorectal tumor. Often, the tumor is a rectal adenoma. With the mortality being certain, if left untreated, it is important to raise awareness on the presentation, diagnosis, and management of this disease entity. Here, we presented 3 cases of McKittrick-Wheelock syndrome that were successfully managed with surgical resection at the Philippine General Hospital from August 2018 to May 2019. Resolution of their symptoms, reversal of their renal impairment, and correction of their electrolyte depletion were noted after removal of the tumor with a sphincter-saving operation.

Purpose: This study aims to evaluate surgical outcomes (i.e. length of stay [LOS], 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the Enhanced Recovery After Surgery (ERAS) pathway, and determine its association with the rate of compliance to the different ERAS components. Methods: This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then retrospectively compared to outcomes prior to the implementation of ERAS. Results: A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92.0% (SR, 91.8%; CR, 93.1%; RR, 90.7%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.1±6.7 days vs. 10.0±5.4 days, P=0.002) and RR (19.9±11.4 days vs. 16.9±10.5 days, P=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar. Conclusion Increased compliance to ERAS protocol is associated with a decrease in morbidity across all surgery types. The implementation of an ERAS protocol significantly decreased mean hospital LOS, without any increase in major surgical complications. Having your own hospital ERAS pathway improves documentation and accuracy of reporting surgical complications.

BACKGROUND AND OBJECTIVE

Robotic surgery for rectal malignancies in the Philippines is emerging. Evidence has shown promising results for robot-assisted (R) rectal surgery when compared to the laparoscopic (L) and open (O) approach. This study discussed the clinicopathologic outcomes of the first robotic rectal resections versus laparoscopic and open rectal resections at the Philippine General Hospital (PGH).

This was a retrospective cohort of 45 consecutive surgical resections for rectal malignancy done at the PGH from March 2019 to October 2019 that compared the outcomes of the first 15 robotic procedures done at the institution versus laparoscopic (n=15) and open (n=15) operations performed during the same time period. One-way ANOVA was done to determine significant differences among variables, while Bonferonni multiple comparison test was done to analyze differences among means.

The 45 patients in the study had a mean age of 56.04 ± 13.45 years. The patients were mostly male (60%). Most of the tumors were located in the low rectum (27/45; 60%). Most of the patients had locally-advanced (at least Stage IIIB) disease (27/45; 60%), and warranted neoadjuvant treatment (41/45; 91.11%). Most patients underwent a sphincter-saving procedure (34/45; 75.56%). All three groups had comparable baseline characteristics. The R-group had the longest operative time (438.07 ± 124.57; p value < 0.0001). Blood loss was significantly highest in the R-group (399 ± 133.07 cc; p value - 0.0020) as well, while no statistical difference was observed between the Oand L-groups (p value – 0.75). No conversion to open was noted in the R- and L-groups. Most of the patients had well-differentiated adenocarcinoma (22/45; 48.49%). All patients in the L- and O-groups had an R0 resection There were two R1 resections in the R-group. All patients who underwent an open surgery had a negative circumferential resection margin (CRM); L-group 93.99%, R-group 69.23%. All patients had adequate proximal and distal resection margins. Those who underwent an open surgery had the shortest post-operative length of stay (LOS) (p value – 0.0002). Post-operative ileus (7/45; 15.56%) was the most commonly encountered morbidity, and was seen mostly in the R-group (3/15; 20%). One patient in the R-group underwent a transanal repair of an anastomotic dehiscence and was discharged three days after reoperation. There was no reported mortality.

Our institution with a beginning robotic colorectal surgery program showed promise as its initial outcomes for rectal cancer were compared to the more often-performed open and laparoscopic procedures. The authors expect more favorable clinicopathological outcomes as our staff overcome the prescribed learning curve for robotic surgery.