Correspondence
Letter to Zhou X. et al. “Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis” doi:10.1111/codi.12802
Dear Editor, We have read with great interest the paper ‘Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study’ by Zhou et al. [1]. We were pleased to have found this technique similar to the transluminal percutaneous ileostomy by probe proposed by our group, which is now conducting a prospective randomized clinical trial [2–4]. We have found some differences compared with our technique, however, and would be grateful if the authors would clarify some aspects. Do they irrigate the colon before the rectal resection? What kind of diet do the patients receive up to removal of the completely diverted tube ileostomy? The authors stated that all anastomotic leaks were treated conservatively. How did they diagnose this complication? Did they assess the durability of the faecal diversion in any way when patients with completely diverted tube ileostomy presented with leakage? Did they investigate any radiological leak? The diverting ileostomy involved the use of a rigid endotracheal tube with an inner diameter of 7 mm left in the ileum for about 30 days. How did the authors determine that the inflated balloon did not cause ischaemia of the ileal wall? Did any patient report discomfort because of the size and rigidity of the tube? How was the site of insertion closed? Did they observe any enteric leakage or enterocutaneous fistula? The staple line of the terminal ileum is likely to be disrupted by the faeces propelled by peristalsis and it has been shown that the inflated balloon of the ileostomy tube does not completely exclude transit of faeces except for the first 8 days approximately [5]. Did any patient report abdominal pain because of the non-passage of faeces owing to the staple line not yet being disrupted? We await your kind feedback.
W. Bugiantella, F. Rondelli and E. Mariani General Surgery, San Giovanni Battista Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy E-mail: [email protected] Received 9 September 2014; accepted 15 September 2014; Accepted Article online 14 October 2014
References 1 Zhou X, Lin C, Chen W, Lin J, Xu J. Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study. Colorectal Dis 2014; 16: O327–31. 2 Rondelli F, Balzarotti R, Bugiantella W, Mariani L, Pugliese R, Mariani E. Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study. Eur J Surg Oncol 2012; 38: 1065–70. 3 Bugiantella W, Rondelli F, Mariani L et al. Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: the ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial. Eur J Surg Oncol 2014; 40: 476–83. 4 Bugiantella W, Rondelli F, Mariani L et al. Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: how to avoid the conventional loop ileostomy. Int J Surg 2014; 12 (Suppl. 2): 144–7. 5 Hanju H, Jiahe X, Caizhao L, Sen L, Jianjiang L. Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy. Colorectal Dis 2014; 16: O117–22.
Reply to Bugiantella et al. doi:10.1111/codi.12801
Dear Sir, We thank Dr Bugiantella and colleagues for their interest in our article recently published in Colorectal Disease [1]. Concerning their first point about preoperative bowel preparation, this procedure remains controversial. Elective colonic resection without mechanical bowel preparation (MBP) has been demonstrated [2,3]. However, data on MBP in rectal cancer surgery are insufficient. A randomized controlled trial showed that rectal cancer surgery without MBP was associated with a higher risk of overall and infectious morbidity but with no significant increase of anastomotic leakage [4]. We felt that no MBP regimen could be an additive risk factor for the postoperative morbidity in surgery of the mid and low rectum. Therefore, we washed the colon before rectal resection, or performed on-table colonic irrigation when the bowel preparation was poor. Regarding the postoperative diet, all patients with completely diverted tube ileostomy (CDTI) were instructed to have a low-residue diet, such as an
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 87–91
87
Correspondence
elemental diet, milk, eggs, gruel, rice, noodles, bread, cake, bean curd, fish, shrimp, meat paste, mashed vegetables and fruit juice, in an attempt to maintain tube patency. Consequently, stoma tube irrigation was seldom required. We do agree with the diagnostic protocol for anastomotic leakage suggested previously [5–8]. In our study, symptoms of anastomotic leakage were evaluated by digital rectal examination (DRE) and proctoscopy followed by plain abdominal CT scan. CT-enema was performed in patients to with suspected postoperative anastomotic leakage if anastomotic dehiscence was not detectable by DRE. We did assess the duration of the complete faecal diversion, measured as the interval between stoma creation and the first bowel action through the anus, when patients with CDTI presented with leakage. In our pilot study, the patients with leakage recovered within this period. Before removal of the catheter, CT-enema was performed to exclude persistent leakage. The tube used for CDTI was a rigid endotracheal tube with an inner diameter of 7 mm, and its balloon was inflated with about 10 ml of water to occupy the ileal lumen without impairing the blood supply of the intestinal wall. Once the bowel regained motility, there was a possibility that the ileal lumen around the balloon could dilate owing to the intestinal peristalsis; thus, it would be impossible to cause ischaemia of the ileal wall even if the tube was left in the ileum for about 30 days. So far, no ischaemia of the terminal ileum has been observed. Harries et al. used a rigid endotracheal tube to create a tube stoma [9]. We felt that the dimension (i.e. inner diameter of 7 mm) and the rigidity of the catheter were necessary for tube patency. Additionally, we cut the catheter short, with only about 2 cm remaining above the abdominal wall, and used a stoma appliance for faecal collection (Fig. 1), which might also contribute to tube patency. As tube irrigation was seldom required, patients with an indwelling catheter could be discharged earlier, with planned removal of the catheter as an outpatient. The discomfort caused by the catheter was no worse than that of a conventional abdomen drainage tube. No patient reported severe pain and no patient asked for earlier removal of the catheter. The site of insertion closed spontaneously in an average of 12 days. Any discharge of small bowel contents from the wound after removal of the catheter resolved spontaneously within 1 month. We did not remove the tube within 3 weeks after creating the tube stoma, aiming to allow for sufficient adhesion formation around the catheter to prevent leakage. To date, we have not had a single case of leakage.
88
Figure 1 The catheter was cut short, with only about 2 cm left above the abdominal wall, and a stoma appliance was used for faecal collection.
In the CDTI technique, the staple line was located 10 cm distal to the tube stoma. Therefore, the volume of faecal contents entering the distal ileum was insufficient to cause abdominal distension before recanalization of the intestine. To date, there is no evidence that faecal transit into the distal ileum before the staple line becomes disrupted leads to abdominal pain.
Conflict of interest None.
X. Zhou, W. Chen and J. Xu Department of Colorectal Surgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, China E-mail: [email protected] Received 30 September 2014; accepted 2 October 2014; Accepted Article online 14 October 2014
References 1 Zhou X, Lin C, Chen W, Lin J, Xu J. Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study. Colorectal Dis 2014; 16: O327–31.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 87–91
Correspondence
2 Slim K, Vicaut E, Launay-Savary MV, Contant C, Chipponi J. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009; 249: 203–9. 3 Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis 2012; 27: 803–10. 4 Bretagnol F, Panis Y, Rullier E et al. Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial. Ann Surg 2010; 252: 863–8. 5 Bugiantella W, Rondelli F, Mariani L et al. Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: the ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial. Eur J Surg Oncol 2014; 40: 476–83. 6 Rondelli F, Mariani L, Boni M, Federici MT, Cappotto FP, Mariani E. Preliminary report of a new technique for temporary faecal diversion after extraperitoneal colorectal anastomosis. Colorectal Dis 2010; 12: 1159–61. 7 Rondelli F, Balzarotti R, Bugiantella W, Mariani L, Pugliese R, Mariani E. Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study. Eur J Surg Oncol 2012; 38: 1065–70. 8 Bugiantella W, Rondelli F, Mariani L et al. Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: how to avoid the conventional loop ileostomy. Int J Surg 2014; 12(Suppl 2): S144–7. 9 Harries K, Shandall AA, Stephenson BM. Endotracheal tube caecostomy. Lancet 1997; 350: 934.
obtained with other techniques such as the artificial bowel sphincter (ABS) [5] and sacral nerve stimulation [6]. Among the complications, the magnetic sphincter caused difficulty in evacuation, as does the ABS [3,4]. These unimpressive results could be explained by fibrosis around the device, as demonstrated by a study in pigs in which a similar magnetic ‘collar’ implanted around the cardia appeared encapsulated in fibrous tissue at a necroscopy carried out after 44 weeks [7]. It is reasonable to suppose that the anal ‘magnetic collar’ could become blocked by fibrin deposition in open or closed position, leading to incontinence or difficulty in evacuation, respectively. Another way of exploiting magnetism for keeping an incompetent anal sphincter closed has been developed in an experimental study in pigs [8], whereby two small magnetic plaques are implanted on both lateral sides of the anal canal, between the internal and external anal sphincters. With opposing poles arranged to attract, the anal lumen is closed and, when the lower rectal pressure becomes more than the pressure in the anal canal, the magnetic plaques get detached and the lumen is opened. This preliminary study, that regrettably was not quoted in the above-mentioned papers, has demonstrated that it is possible to create a ‘magnetic valve’ with a dynamic closure sufficient to prevent faecal incontinence but without the risk of creating circumferential fibrosis, because the magnetic plaques are separated by the anal lumen.
Conflicts of interest There is no conflict of interest.
The magnetic anal sphincter: a seductive promise still not kept doi:10.1111/codi.12803
Dear Sir, The idea of increasing anal sphincter strength to prevent faecal incontinence by using a magnetic device reminds us of a previously published idea for avoiding gastroesophageal reflux [1] developed and perfected as the ‘magnetic collar’ [2]. The ‘collar’ was adapted to reinforce the anal sphincter in patients with faecal incontinence, but the first results have not been exciting. In fact the preliminary report [3] showed an improvement at 6 months in only five of 14 patients, with an average increase of only 12 mmHg in anal resting pressure; in another study [4] the Wexner score decreased by only about 50% in 19 patients assessed at 6 months. These results are no better than those
M. Bortolotti Department of Internal Medicine and Gastroenterology, University of Bologna, Via Massarenti 48, Bologna, 40138, Italy E-mail: [email protected] Received 19 September 2014; accepted 20 September 2014; Accepted Article online 14 October 2014
References 1 Bortolotti M. A novel antireflux device based on magnets. J Biomech 2006; 39: 564–7 (sent in 2003). 2 Ganz RA, Peters JH, Horgan S et al. Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med 2013; 368: 719–27. 3 Lehur P-A, McNevin S, Buntzen S, Mellgren AF, Laurberg S, Madoff RD. Magnetic anal sphincter augmentation for the treatment of fecal incontinence: a preliminary report from a feasibility study. Dis Colon Rectum 2010; 53: 1604–10.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 87–91
89
Letter to Zhou X. et al. “Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis” doi:10.1111/codi.12802
Dear Editor, We have read with great interest the paper ‘Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study’ by Zhou et al. [1]. We were pleased to have found this technique similar to the transluminal percutaneous ileostomy by probe proposed by our group, which is now conducting a prospective randomized clinical trial [2–4]. We have found some differences compared with our technique, however, and would be grateful if the authors would clarify some aspects. Do they irrigate the colon before the rectal resection? What kind of diet do the patients receive up to removal of the completely diverted tube ileostomy? The authors stated that all anastomotic leaks were treated conservatively. How did they diagnose this complication? Did they assess the durability of the faecal diversion in any way when patients with completely diverted tube ileostomy presented with leakage? Did they investigate any radiological leak? The diverting ileostomy involved the use of a rigid endotracheal tube with an inner diameter of 7 mm left in the ileum for about 30 days. How did the authors determine that the inflated balloon did not cause ischaemia of the ileal wall? Did any patient report discomfort because of the size and rigidity of the tube? How was the site of insertion closed? Did they observe any enteric leakage or enterocutaneous fistula? The staple line of the terminal ileum is likely to be disrupted by the faeces propelled by peristalsis and it has been shown that the inflated balloon of the ileostomy tube does not completely exclude transit of faeces except for the first 8 days approximately [5]. Did any patient report abdominal pain because of the non-passage of faeces owing to the staple line not yet being disrupted? We await your kind feedback.
W. Bugiantella, F. Rondelli and E. Mariani General Surgery, San Giovanni Battista Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy E-mail: [email protected] Received 9 September 2014; accepted 15 September 2014; Accepted Article online 14 October 2014
References 1 Zhou X, Lin C, Chen W, Lin J, Xu J. Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study. Colorectal Dis 2014; 16: O327–31. 2 Rondelli F, Balzarotti R, Bugiantella W, Mariani L, Pugliese R, Mariani E. Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study. Eur J Surg Oncol 2012; 38: 1065–70. 3 Bugiantella W, Rondelli F, Mariani L et al. Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: the ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial. Eur J Surg Oncol 2014; 40: 476–83. 4 Bugiantella W, Rondelli F, Mariani L et al. Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: how to avoid the conventional loop ileostomy. Int J Surg 2014; 12 (Suppl. 2): 144–7. 5 Hanju H, Jiahe X, Caizhao L, Sen L, Jianjiang L. Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy. Colorectal Dis 2014; 16: O117–22.
Reply to Bugiantella et al. doi:10.1111/codi.12801
Dear Sir, We thank Dr Bugiantella and colleagues for their interest in our article recently published in Colorectal Disease [1]. Concerning their first point about preoperative bowel preparation, this procedure remains controversial. Elective colonic resection without mechanical bowel preparation (MBP) has been demonstrated [2,3]. However, data on MBP in rectal cancer surgery are insufficient. A randomized controlled trial showed that rectal cancer surgery without MBP was associated with a higher risk of overall and infectious morbidity but with no significant increase of anastomotic leakage [4]. We felt that no MBP regimen could be an additive risk factor for the postoperative morbidity in surgery of the mid and low rectum. Therefore, we washed the colon before rectal resection, or performed on-table colonic irrigation when the bowel preparation was poor. Regarding the postoperative diet, all patients with completely diverted tube ileostomy (CDTI) were instructed to have a low-residue diet, such as an
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 87–91
87
Correspondence
elemental diet, milk, eggs, gruel, rice, noodles, bread, cake, bean curd, fish, shrimp, meat paste, mashed vegetables and fruit juice, in an attempt to maintain tube patency. Consequently, stoma tube irrigation was seldom required. We do agree with the diagnostic protocol for anastomotic leakage suggested previously [5–8]. In our study, symptoms of anastomotic leakage were evaluated by digital rectal examination (DRE) and proctoscopy followed by plain abdominal CT scan. CT-enema was performed in patients to with suspected postoperative anastomotic leakage if anastomotic dehiscence was not detectable by DRE. We did assess the duration of the complete faecal diversion, measured as the interval between stoma creation and the first bowel action through the anus, when patients with CDTI presented with leakage. In our pilot study, the patients with leakage recovered within this period. Before removal of the catheter, CT-enema was performed to exclude persistent leakage. The tube used for CDTI was a rigid endotracheal tube with an inner diameter of 7 mm, and its balloon was inflated with about 10 ml of water to occupy the ileal lumen without impairing the blood supply of the intestinal wall. Once the bowel regained motility, there was a possibility that the ileal lumen around the balloon could dilate owing to the intestinal peristalsis; thus, it would be impossible to cause ischaemia of the ileal wall even if the tube was left in the ileum for about 30 days. So far, no ischaemia of the terminal ileum has been observed. Harries et al. used a rigid endotracheal tube to create a tube stoma [9]. We felt that the dimension (i.e. inner diameter of 7 mm) and the rigidity of the catheter were necessary for tube patency. Additionally, we cut the catheter short, with only about 2 cm remaining above the abdominal wall, and used a stoma appliance for faecal collection (Fig. 1), which might also contribute to tube patency. As tube irrigation was seldom required, patients with an indwelling catheter could be discharged earlier, with planned removal of the catheter as an outpatient. The discomfort caused by the catheter was no worse than that of a conventional abdomen drainage tube. No patient reported severe pain and no patient asked for earlier removal of the catheter. The site of insertion closed spontaneously in an average of 12 days. Any discharge of small bowel contents from the wound after removal of the catheter resolved spontaneously within 1 month. We did not remove the tube within 3 weeks after creating the tube stoma, aiming to allow for sufficient adhesion formation around the catheter to prevent leakage. To date, we have not had a single case of leakage.
88
Figure 1 The catheter was cut short, with only about 2 cm left above the abdominal wall, and a stoma appliance was used for faecal collection.
In the CDTI technique, the staple line was located 10 cm distal to the tube stoma. Therefore, the volume of faecal contents entering the distal ileum was insufficient to cause abdominal distension before recanalization of the intestine. To date, there is no evidence that faecal transit into the distal ileum before the staple line becomes disrupted leads to abdominal pain.
Conflict of interest None.
X. Zhou, W. Chen and J. Xu Department of Colorectal Surgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, China E-mail: [email protected] Received 30 September 2014; accepted 2 October 2014; Accepted Article online 14 October 2014
References 1 Zhou X, Lin C, Chen W, Lin J, Xu J. Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study. Colorectal Dis 2014; 16: O327–31.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 87–91
Correspondence
2 Slim K, Vicaut E, Launay-Savary MV, Contant C, Chipponi J. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009; 249: 203–9. 3 Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis 2012; 27: 803–10. 4 Bretagnol F, Panis Y, Rullier E et al. Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial. Ann Surg 2010; 252: 863–8. 5 Bugiantella W, Rondelli F, Mariani L et al. Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: the ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial. Eur J Surg Oncol 2014; 40: 476–83. 6 Rondelli F, Mariani L, Boni M, Federici MT, Cappotto FP, Mariani E. Preliminary report of a new technique for temporary faecal diversion after extraperitoneal colorectal anastomosis. Colorectal Dis 2010; 12: 1159–61. 7 Rondelli F, Balzarotti R, Bugiantella W, Mariani L, Pugliese R, Mariani E. Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study. Eur J Surg Oncol 2012; 38: 1065–70. 8 Bugiantella W, Rondelli F, Mariani L et al. Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: how to avoid the conventional loop ileostomy. Int J Surg 2014; 12(Suppl 2): S144–7. 9 Harries K, Shandall AA, Stephenson BM. Endotracheal tube caecostomy. Lancet 1997; 350: 934.
obtained with other techniques such as the artificial bowel sphincter (ABS) [5] and sacral nerve stimulation [6]. Among the complications, the magnetic sphincter caused difficulty in evacuation, as does the ABS [3,4]. These unimpressive results could be explained by fibrosis around the device, as demonstrated by a study in pigs in which a similar magnetic ‘collar’ implanted around the cardia appeared encapsulated in fibrous tissue at a necroscopy carried out after 44 weeks [7]. It is reasonable to suppose that the anal ‘magnetic collar’ could become blocked by fibrin deposition in open or closed position, leading to incontinence or difficulty in evacuation, respectively. Another way of exploiting magnetism for keeping an incompetent anal sphincter closed has been developed in an experimental study in pigs [8], whereby two small magnetic plaques are implanted on both lateral sides of the anal canal, between the internal and external anal sphincters. With opposing poles arranged to attract, the anal lumen is closed and, when the lower rectal pressure becomes more than the pressure in the anal canal, the magnetic plaques get detached and the lumen is opened. This preliminary study, that regrettably was not quoted in the above-mentioned papers, has demonstrated that it is possible to create a ‘magnetic valve’ with a dynamic closure sufficient to prevent faecal incontinence but without the risk of creating circumferential fibrosis, because the magnetic plaques are separated by the anal lumen.
Conflicts of interest There is no conflict of interest.
The magnetic anal sphincter: a seductive promise still not kept doi:10.1111/codi.12803
Dear Sir, The idea of increasing anal sphincter strength to prevent faecal incontinence by using a magnetic device reminds us of a previously published idea for avoiding gastroesophageal reflux [1] developed and perfected as the ‘magnetic collar’ [2]. The ‘collar’ was adapted to reinforce the anal sphincter in patients with faecal incontinence, but the first results have not been exciting. In fact the preliminary report [3] showed an improvement at 6 months in only five of 14 patients, with an average increase of only 12 mmHg in anal resting pressure; in another study [4] the Wexner score decreased by only about 50% in 19 patients assessed at 6 months. These results are no better than those
M. Bortolotti Department of Internal Medicine and Gastroenterology, University of Bologna, Via Massarenti 48, Bologna, 40138, Italy E-mail: [email protected] Received 19 September 2014; accepted 20 September 2014; Accepted Article online 14 October 2014
References 1 Bortolotti M. A novel antireflux device based on magnets. J Biomech 2006; 39: 564–7 (sent in 2003). 2 Ganz RA, Peters JH, Horgan S et al. Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med 2013; 368: 719–27. 3 Lehur P-A, McNevin S, Buntzen S, Mellgren AF, Laurberg S, Madoff RD. Magnetic anal sphincter augmentation for the treatment of fecal incontinence: a preliminary report from a feasibility study. Dis Colon Rectum 2010; 53: 1604–10.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 87–91
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