Diseases of the colon and rectum
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Surgery for locally advanced and recurrent rectal carcinoma sometimes requires partial resection of the perineum and/or vagina necessitating subsequent reconstruction. ⋯ Reconstruction of the perineum and/or dorsal vagina was successful in all patients. Surgeons and gynecologists who use the vertical rectus abdominis myocutaneous flap should be aware of stenosis of the vaginal introitus. Gynecological consultation at an early stage should be standard.
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Accidental puncture or laceration during a surgical procedure is a patient safety indicator that is publicly reported and will factor into the Centers for Medicare and Medicaid's pay-for-performance plan. Accidental puncture or laceration includes serosal tear, enterotomy, and injury to the ureter, bladder, spleen, or blood vessels. ⋯ Accidental puncture or laceration is more likely to occur in complex colorectal operations. The clinical consequences range from none to significant depending on the specific type of injury. To make accidental puncture or laceration a more meaningful quality indicator, we advocate that groups who use the measure eliminate the injuries that have no bearing on surgical outcome and that risk adjustment for operative complexity is performed.
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Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection. ⋯ A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.
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Comparative Study
Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis.
A laparoscopic approach has been proposed to reduce the high morbidity and mortality associated with the Hartmann procedure for the emergency treatment of diverticulitis. ⋯ A laparoscopic approach to the Hartmann procedure for the emergency treatment of complicated diverticulitis does not significantly decrease postoperative morbidity or mortality in comparison with the open technique.
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Comprehensive analyses are lacking to identify predictors of postoperative complications in patients who undergo a Hartmann reversal. ⋯ Hartmann reversal is associated with significant morbidity; BMI independently predicts complications. Therefore, patients who are obese should be encouraged or even potentially required to lose weight before reversal.