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The large intestine
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Restorative proctocolectomy with an ileoanal pouch (Parks) In this operation, a pouch is made out of ileum (Figure70.16) as a substitute for the rectum and sewn or stapled to the anal canal. This avoids a permanent stoma. It is reserved for patients with adequate anal sphincters and should be avoided if CD is a possibility. Various pouch designs have been described, but the ‘J' is the most popular and the most easily made using staplers (Figure70.17). There is some controversy over the correct technique for ileoanal anastomosis. In the earliest operations, the mucosa from the dentate line up to mid-rectum was stripped off the underlying muscle, but it is now known that a long muscle cuff is not needed. Although mucosectomy of the upper anal canal with an anastomosis at the dentate line is claimed to remove all of the at-risk mucosa and any problem of subsequent cancer, it may also increase the risk of incontinence with nocturnal seepage. The alternative is an anastomosis double-stapled to the top of the anal canal, preserving the upper anal mucosa. Continence appears to be better, but there is a theoretical risk of leaving inflamed mucosa behind. The procedure can be carried out in stages and a covering loop ileostomy is virtually always used.
Coloanal Anastomosis with intersphincteric Resection and Colon J-Pouch Construction
Published in P Ronan O’Connell, Robert D Madoff, Stanley M Goldberg, Michael J Solomon, Norman S Williams, Operative Surgery of the Colon, Rectum and Anus Operative Surgery of the Colon, Rectum and Anus, 2015
If a handsewn coloanal anastomosis is to be performed, as it is impossible to place a crushing clamp and a stapler below the tumor, the mucosa of therectal stump, below the level of the clamp must be removed. Once the rectal stump has been irrigated after application of a right-angle crushing retractor, a Lone Star™ retractor (Lone Star Medical Products, Houston, TX, USA) is applied. Subsequent mucosal dissection is facilitated by injection of saline containing adrenaline (1:10 000) into the submucosal plane to ‘float’ the mucosa away from the underlying muscle Figure 6.5.11.mucosa is removed from5 mm above the dentate line in a circumferential manner using sharp-pointed scissor dissection and simultaneous coagulation of allbleeding points. The mucosectomy continues upwards until the upper part of the sphincter is reached, corresponding to the point reached during the abdominal dissection. This allows the specimen to be removed from the abdomen en bloc with the rectum before transection of the colon. Hemostasis of the anorectal muscular stump is reviewed as well as hemostasis in the lower pelvis, after irrigation with warm saline from the abdomen.
Oesophageal cancer
Published in Pat Price, Karol Sikora, Treatment of Cancer, 2014
Brian J. Haylock, Amir H. Montazeri
Endoscopic treatment options are available for patients with early-stage tumours but who are too ill to undergo surgery or who refuse surgery or RT. Endoscopic mucosal resection or endoscopic mucosectomy can be curative in selected patients, with early disease, and provides a histological specimen that can be evaluated for adequacy of resection margins. The technique has traditionally involved lifting the mucosa by submucosal injection of saline and endoscopic suction into an overtube in which a snare is fitted.
Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries
Published in Paediatrics and International Child Health, 2019
Anthony Mark Dalzell, Muhammad Eyad Ba’Ath
In UC, unresponsiveness to intravenous steroid therapy, anaemia and the need for blood transfusion are major predictors of colectomy [81]. In some studies, the rectal sparing type has been identified as an independent risk factor for urgent/emergent surgery in surgically treated patients with UC [82]. Acute indications include toxic megacolon which is rare in children. Surgical options in UC include total or subtotal colectomy with ileorectal anastomosis and subsequent lifelong surveillance of the rectal pouch. If total colectomy with rectal mucosectomy is to be performed, then reconstruction options include J-pouch ileo-anal anastomosis, straight ileo-anal anastomosis and permanent ileostomy which is usually necessary in about 10% of patients [80]. In toxic megacolon, blow-hole colostomy (construction of a side hole through the colon wall which is sutured to the skin and allows the colon to decompress, thus avoiding perforation) might be an option if a patient is too sick to tolerate a more extensive procedure.
Differentiation between malignant and benign rectal tumors by dual-energy computed tomography - a feasibility study
Published in Acta Oncologica, 2019
Issam Al-Najami, Hussam Mahmoud Sheta, Gunnar Baatrup
Despite the use of several imaging modalities, we still need a more accurate imaging modality to differentiate between advanced rectal adenomas and rectal carcinomas. The correct diagnosis is crucial for further treatment. Patients with benign lesions should be offered an organ-sparing treatment by a mucosectomy either by transanal endoscopic microsurgery (TEM), endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) [3,4]. Patients with malignant lesions should be offered a more in-depth surgery with a full wall thickness local resection, or a segmental bowel resection [5]. This treatment is associated with higher rates of morbidity, and a careful selection is therefore important.
Antireflux mucosectomy for managing reflux symptoms in an obese patient post laparoscopic sleeve gastrectomy
Published in Scandinavian Journal of Gastroenterology, 2019
Gaurav Patil, Arun Iyer, Ankit Dalal, Amit Maydeo
After 12 h fasting and appropriate premorbidity medications, the procedure was done with patient in supine position under general anesthesia (with endotracheal intubation). Hypotensive anesthesia was used [11]. This was achieved by using intravenous micro-drip of nitroglycerin which permitted maintenance of constant infusion rate. Nitroglycerin can often cause reflex tachycardia. This was overcome by using oral Clonidine 100 mcg 2 h prior to procedure as a premedicant. An Endoscopic mucosal resection (EMR) kit (Olympus, Tokyo, Japan) was fixed onto a GIF HQ190 upper endoscope (Olympus). The scope was advanced, esophagus and stomach were examined (Figure 1). The procedure was done in retroflexion. By using forced coagulation current with a dual knife (Olympus) with endocautery settings of effect 2, 50 W (VIO® 3 ERBE Electromedizin, Tübingen, Germany), we marked mucosal area of the gastric cardia occupying two-thirds of the circumference along the lesser curvature (Figure 2). After injecting the mucosa with saline combined with 2% indigo carmine, cap-EMR was used together with thin diameter snare (Olympus), piecemeal EMR was performed in a crescentic fashion (Figure 3). The mucosectomy was repeatedly performed until the mucosal zone was completely resected (Figure 4). Hemostasis of the vessels was achieved with a coagrasper hemostatic forceps (Olympus). The total duration of the procedure was 89 min. With Hills Grade 3, we resected (vertical extent) about 1.5–2 cm in width with appropriate circumferential coverage. The mucosal area is usually estimated as twice the width of the endoscope circumference in retroflex view from stomach. By performing mucosectomy on the lesser curvature, it rebuilds a robust angle of His.