OBJECTIVETo compare the safety and efficacy of the medial approach(MA) and the lateral approach (LA) in the treatment of colorectal disease.

METHODSStudies published from January 1994 to April 2013 that compared MA to LA in laparoscopic colorectal resection were collected. Publications in English were mainly identified from Medline, Embase, Cochrane Library, and those in Chinese from Wanfang database and CNKI database. Conversion rate, operative time, blood loss, number of harvested lymph nodes, hospital stay, complication, mortality, recurrence, and hospitalization costs of MA and LA were meta-analyzed using fixed-effect and random-effect models.

RESULTSFive cohort studies (2 randomized controlled trials and 3 retrospective studies) including 881 patients were enrolled and analyzed. Of these patients, 416 and 465 underwent laparoscopic colorectal resection with MA and LA respectively. As compared to LA, MA had significantly lower conversion rate (OR=0.42, 95%CI:0.25-0.72, P=0.001), shorter operative time (WMD=-52.62, 95%CI:-63.23--42.01, P<0.01), less number of harvested lymph nodes (WMD=-1.17, 95%CI:-1.89--0.45, P=0.001), while blood loss was less and hospitalization cost lower. Significant differences in intraoperative complications and postoperative complications were not found between the two group (OR:0.57, 95%CI:0.15-2.18, P=0.41; OR:0.78, 95%CI:0.52-1.17, P=0.23).

CONCLUSIONSCompared with LA, MA has the advantages of shorter operative time and lower conversion rate with similar safety. Differences in blood loss, hospitalization cost and oncological safety between the two approaches warrant further investigation.

Humans ; Laparoscopy ; methods ; Proctocolectomy, Restorative ; methods

Familial adenomatous polyposis(FAP) has a significant risk of developing colorectal cancer. As a consequence, their surgical treatment is currently widely performed by restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA). Frequently, the potential for recurrence in FAP patients after above operation was overlooked. In fact, several reports were presented for warning of recurred cancer in ileal pouch. We report a case of a patient who developed adenocarcinoma in an ileal pouch after restorative proctocolectomy for familial adenomatous polyposis with a review of literature.
Adenocarcinoma ; Adenomatous Polyposis Coli ; Colorectal Neoplasms ; Humans ; Proctocolectomy, Restorative ; Recurrence

Adult ; Anastomosis, Surgical ; Constipation/surgery* ; Humans ; Megacolon/surgery* ; Proctocolectomy, Restorative

The distinctive diagnosis of Crohn's disease (CD) and ulcerative colitis (UC) is based on a combination of clinical, histologic, endoscopic, and radiologic data. Both UC and CD show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of indeterminate colitis (IC), which was proposed by pathologists for colectomy specimens in 1978, usually from patients operated on for severe colitis, especially in cases of acute fulminant disease of the colorectum. The subgroup of patients with an uncertain diagnosis has been classified as IC. Later, the same terminology was used for patients showing no clear clinical, endoscopic, histologic, or other features allowing a diagnosis of either UC or CD. More recently, the term IC has been applied to biopsy material when it is not been possible to differentiate between UC and CD. However, this term IC has suffered varying definitions, which in addition to numerous difficulties in diagnosing inflammatory bowel disease, has led to much confusion. In resected specimens, the term colitis of uncertain type or etiology is preferred. Over time, the majority of patients remain with a diagnosis of IC or show symptoms similar to UC. Ileal pouch anal anastomosis can be performed in such patients, with outcomes of pouch failure and with functional outcomes that are similar to those in patients with UC, but with increased risk of postoperative pouch complications. This review addresses the definition of indeterminate colitis, its pathology, its natural history, and the outcomes of restorative proctocolectomy.
Biopsy ; Colectomy ; Colitis ; Colitis, Ulcerative ; Crohn Disease ; Humans ; Inflammatory Bowel Diseases ; Natural History ; Proctocolectomy, Restorative

PURPOSE: The aims of this investigation were to access the relative ratio of epithelial types within the anal canal after a double-stapled ileoanal reservoir (DSIAR) and to review physiologic and functional differences based on this diversity in epithelial types. METHODS: According to types of the epithelium present at histologic sections of the distally excised tissue ring ("donut") after the stapling for restorative proctocolectomy with construction of a DSIAR, one hundred thirty-eight patients with ulcerative colitis were stratified into two groups: 40 patients (22 males and 18 females) were categorized to be of lower anastomosis (group I), where squamous, squamous mixed with columnar, or squamocuboidal component was reported to be present, and 98 patients (50 males and 48 females) to be of higher one (group II), which was evidenced by columnar epithelium at the "donut". Physiologic and functional parameters were appraised between 2 groups to define whether this difference in epithelial types is associated with a significant difference in postoperative anorectal functional outcome. RESULTS: None of preoperative parameters reflecting resting and squeeze pressures showed significant differences between 2 groups. Postoperative mean and maximal resting pressures (MRP and MxRP) were declined to 48.8 16.9 mmHg and 67.1 21.3 mmHg in group I, and 61.1 22.7 mmHg and 90.0 38.6 mmHg in group II, differences of which were significant (P=0.046 and 0.031, respectively). Neither postoperative mean nor maximal squeeze pressure was, however, statistically different between 2 groups. Mean length of the high pressure zone was decreased in both groups postoperatively, but there were no intergroup differences. Rectoanal inhibitory reflex decreased significantly from 97.4% to 50% in group I and from 86.5% to 53.9% in group II, respectively (P<0.0001 in both). However, there was no significant intergroup difference postoperatively. Maximal tolerance volume and compliance of the reservoir were significantly improved postoperatively in both groups; from 52.2 26.1 ml and 2.8 3.3 to 163.3 115.7 ml and 14.7 15.3 in group I (P=0.0001, and <.0001, respectively), and from 77.0 59.5 ml and 4.4 6.8 to 167.3 87.9 ml and 28.7 44.0 in group II (P<0.0001, both). But there was no intergroup difference in either parameters postoperatively. There were no significant differences between groups relative to functional outcome except the diurnal incontinence to solid stool (P<0.011). CONCLUSIONS: Although epithelial types were shown to be variable at the anal side of the anastomosis after a DSIAR, these differences were not associated with physiologic and functional differences. Therefore, if technically feasible, this procedure can be performed with safety without fear of significant functional derangement.
Anal Canal* ; Colitis, Ulcerative ; Colonic Pouches* ; Compliance ; Epithelium ; Humans ; Male ; Proctocolectomy, Restorative ; Reflex

PURPOSE: To evaluate the effectiveness of a P-pouch configuration with a reservoir and recycled segment in restorative proctocolectomy. METHODS: There were 11 patients who underwent the P-pouch procedure. They were compared with healthy eight-control subjects. The P-pouch configuration was constructed using one firing of a 10 cm GIA stapler to form a 12-cm reservoir. Following that, the distal ileum (15+/-0.5 cm) was anastomosed to the proximal portion of the pouch. Pouch function was studied 23.3+/-4.4 months after ileostomy closure. We measured the frequency and amount of stool. The postprandial plasma peptide YY (PYY) response and the scintigraphic studies using 99m-Tc sulfur colloid were used to study transit. RESULTS: In the patient group, daily stool frequency and volume were 5.2+/-0.3 and 423.5+/-23.7 g, respectively. Stool seepage and pouchitis occurred in 45.5 % and 9.1%. In contrast to other pouch procedures, the postprandial increment of plasma PYY was similar the P-pouch patients and healthy controls (P>0.05). The integrated increment of plasma PYY for 180 minutes following meals was also not decreased in 9-pouch patient group compared with the healthy controls (1,050.0+/-127.8 pmol/l vs. 1146.0+/-150.0 pmol/l, P>0.05). Small intestinal transit time for healthy controls and the patient group averaged 89+/-21 and 117+/-12 minutes (P>0.05). The capacity of the ileal pouch was 372+/-22 ml, and the efficiency of ileal reservoir evacuation was 76 %. CONCLUSIONS: The P-pouch is a new and improved simple modification of the well-established J-pouch procedure, constructed using a single firing of a GIA stapler.
Colloids ; Colonic Pouches* ; Fires ; Humans ; Ileostomy ; Ileum ; Meals ; Peptide YY ; Plasma ; Pouchitis ; Proctocolectomy, Restorative* ; Sulfur

PURPOSE: Restorative proctocolectomy with an ileal pouch anal anastomosis (IPAA) is the main surgical treatment for patients with familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery, proctocolectomy with an ileal pouch anal anastomosis is increasingly being done by laparoscopic methods. This report aims to compare the presumed benefits of the laparoscopic approach with that of open surgery. METHODS: We reviewed 25 patients who underwent total proctocolectomy with IPAA between 1994 and 2009. The data of 9 patients who underwent laparoscopic surgery was analyzed and compared with the data of 16 patients who underwent the conventional open surgery. RESULTS: Laparoscopic proctocolectomy with an ileal pouch anal anastomosis (IPAA) was performed successfully without severe complications in 9 patients. The mean operation time of the laparoscopic group was 352 min, and this was significantly longer than that of the conventional group (252 min). The mean intra-operative blood loss, time to first flatulance, the hospital stay and the time to starting an oral diet were not significantly different from that of the open group. CONCLUSION: Laparoscopic IPAA is a feasible and safe procedure due to the reduced trauma and pain and a more favorable cosmetic result. As the technique and instrumentation for laparoscopic colon surgery are developed, this procedure will likely become an appealing option for the management of patients with FAP.
Adenomatous Polyposis Coli ; Colon ; Cosmetics ; Diet ; Humans ; Laparoscopy ; Length of Stay ; Proctocolectomy, Restorative

We report seven adolescents presenting with hematochezia. Five had a family history of colonic polyps or cancer. Colonoscopy showed either multiple pedunculated and/or sessile polyps with partial or total colonic involvement. Polyphistopathology was of the juvenile retention, hamartomatous or tubular adenomatous type. Total proctocolectomy was done in four patients, two underwent repeated polypectomy, and one is awaiting further treatment. An increased awareness of colonic polyposis is important due to the risk of malignant transformation.

Human ; Male ; Female ; Adolescent ; Child ; Adolescent ; Colonic Polyps ; Proctocolectomy, Restorative ; Colonoscopy ; Colon ; Gastrointestinal Hemorrhage ; Adenoma

Restorative proctocolectomy (RPC), when performed with a stapled ileal pouch-anal anastomosis (IPAA), allows the retention of the rectal mucosa above the dentate line and can result in disease persistence or recurrence, as well as neoplastic lesions in patients with ulcerative colitis (UC). We report the case of a patient with chronic UC who underwent staple mucosectomy, which is an alternative technique that evolved from stapled hemorrhoidopexy, rather than more traditional procedures. The patient had undergone laparoscopic RPC with a stapled IPAA 2 cm above the dentate line and a temporary loop ileostomy. Because the histopathology showed low-grade dysplasia in the proximal rectum, stapled mucosectomy with a 33-mm circular stapler kit at the time of ileostomy closure was scheduled. Following the application of a purse-string suture 1 cm above the dentate line, the stapler was inserted with its anvil beyond the purse-string and was fired. The excised rectal tissue was checked to ensure that it was a complete cylindrical doughnut. Histopathology of the excised tissue showed chronic inflammation. There were no complications during a follow-up period of 5 months. Because it preserves the normal rectal mucosal architecture and avoids a complex mucosectomy surgery, stapled mucosectomy seems to be a technically feasible and clinically acceptable alternative to the removal of rectal mucosa retained after RPC.
Colitis, Ulcerative ; Dietary Sucrose ; Fires ; Follow-Up Studies ; Humans ; Ileostomy ; Inflammation ; Mucous Membrane ; Proctocolectomy, Restorative ; Rectum ; Recurrence ; Retention (Psychology) ; Sutures

OBJECTIVETo discuss a new surgical strategy: Jinling procedure (subtotal colectomy combined with modified Duhamel procedure), of which the indications, technical notes and outcomes were analyzed.

METHODSThe 590 patients with refractory slow-transit constipation associated with outlet obstruction was strictly included between February 2000 and December 2011. The patients included 103 males and 487 females. Their age were 14-75 years (average 42 ± 13). The 412 patients received laparoscopic-assistant Jinling procedure, and 178 patients with open Jinling procedure. The pre- and post-operation data were collected. The follow up rate were 100%, 98.1%, 95.8% and 92.7% at 3, 6, 12 and 24 months.

RESULTSThere was no surgery-related death. Mean hospital day was (12 ± 9) days. Most complications were managed conservatively without significant events. The common complications after surgery were adhesive intestinal obstruction (9.2%), anastomosis bleeding (8.1%) and anastomosis leakage (2.9%). The gastrointestinal quality of life index score was 72 ± 9 preoperatively and increased to 68 ± 11, 99 ± 6, 105 ± 9, 106 ± 9 at 3, 6, 12 and 24 month follow-up, respectively (t = 62.1, -25.1, -126.5, -143.2, P < 0.01). The Wexner constipation scale was 21.9 ± 4.5 preoperatively and decreased to 9.6 ± 2.4, 5.9 ± 2.1, 4.6 ± 1.9, 4.5 ± 1.8 at 3, 6, 12 and 24 month follow-up, respectively (t = 48.6, 61.8, 58.2, 45.9, P < 0.01). The satisfactory rate was 77.5%, 92.1%, 93.0% and 94.1% at 3, 6, 12, and 24 month follow-up.

CONCLUSIONSJinling procedure provides a good surgical option for refractory slow-transit constipation associated with outlet obstruction.

Adolescent ; Adult ; Aged ; Constipation ; surgery ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Proctocolectomy, Restorative ; methods ; Treatment Outcome ; Young Adult