Surgical treatment of anal stenosis Brisinda, Giuseppe; Vanella, Serafino; Cadeddu, Federica ...
World journal of gastroenterology : WJG,
04/2009, Letnik:
15, Številka:
16
Journal Article
Odprti dostop
Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A ...Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.
Puborectalis syndrome remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, laxatives, enemas, biofeedback training, and surgery. These often were tried ...sequentially and had conflicting or even disappointing results. We investigated the efficacy of injections of botulinum toxin in improving rectal emptying in patients with defecatory disorders involving spastic pelvic-floor muscles.
Twenty-four consecutive patients with chronic outlet obstruction constipation resulting from puborectalis syndrome were included in the study. The patients were treated with 60 units of type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance.
At 2 months, evaluation inspection revealed a symptomatic improvement in 19 patients. Anorectal manometry demonstrated decreased tone during straining from 98 +/- 24 to 56 +/- 20 mmHg at a 1-month evaluation (p < 0.01) and 56 +/- 29 mmHg at a 2-month follow-up (p < 0.01). Pressure during straining was lower than resting anal pressure at the same time in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 98 +/- 9 degrees to 121 +/- 15 degrees (p < 0.01).
Botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective, especially with the use of the ultrasonographic guidance that accounts for a more precise injection and consequently better long-term results. Otherwise, given the limited effect of the toxin, repeated injections may be necessary to maintain the clinical improvement.
Background
In recent years, the emergency management of acute left colonic diverticulitis (ALCD) has evolved dramatically despite lack of strong evidence. As a consequence, management strategies are ...frequently guided by surgeon’s personal preference, rather than by scientific evidence. The primary aim of IPOD study (Italian Prospective Observational Diverticulitis study) is to describe both the diagnostic and treatment profiles of patients with ALCD in the Italian surgical departments.
Methods
IPOD study is a prospective observational study performed during a 6-month period (from April 1 2015 to September 1 2015) and including 89 Italian surgical departments. All consecutive patients with suspected clinical diagnosis of ALCD confirmed by imaging and seen by a surgeon were included in the study. The study was promoted by the Italian Society of Hospital Surgeons and the World Society of Emergency Surgery Italian chapter.
Results
Eleven hundred and twenty-five patients with a median age of 62 years interquartile range (IQR), 51–74 were enrolled in the IPOD study. One thousand and fifty-four (93.7%) patients were hospitalized with a median duration of hospitalization of 7 days (IQR 5–10). Eight hundred and twenty-eight patients (73.6%) underwent medical treatment alone, 13 patients had percutaneous drainage (1.2%), and the other 284 (25.2%) patients underwent surgery as first treatment. Among 121 patients having diffuse peritonitis, 71 (58.7%) underwent Hartmann’s resection. However, the Hartmann’s resection was used even in patients with lower stages of ALCD (36/479; 7.5%) where other treatment options could be more adequate.
Conclusions
The IPOD study demonstrates that in the Italian surgical departments treatment strategies for ALCD are often guided by the surgeon’s personal preference.
Recent reports confirm that the management of chronic anal fissure has undergone extensive re-evaluation during the past few years. This rejuvenation of interest is attributable to the application of ...neurochemical treatment, which has contributed to the tendency to treat the disease on an outpatient basis. The use of botulinum neurotoxin seems to be a promising and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence. Indeed, botulinum neurotoxin has been successfully used selectively to weaken the internal anal sphincter as a treatment for chronic anal fissure. It is also more efficacious than nitrate therapy, and is not related to the patient's willingness to complete treatment.
Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other ...disorders characterized by excessive or inappropriate muscle contractions. The use of this pluripotential agent has extended to a plethora of conditions including: focal dystonia; spasticity; inappropriate contraction in most sphincters of the body such as those associated with spasmodic dysphonia, esophageal achalasia, chronic anal fissure, and vaginismus; eye movement disorders; other hyperkinetic disorders including tics and tremors; autonomic disorders such as hyperhidrosis; genitourinary disorders such as overactive and neurogenic bladder, nonbacterial prostatitis and benign prostatic hyperplasia; and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of the pain, and for the management of tension or migraine headaches and myofascial pain syndrome. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease. Systemic pharmacologic effects are rare; permanent destruction of tissue does not occur. Graded degrees of relaxation may be achieved by varying the dose injected; most adverse effects are transient. Finally, patient acceptance is high. In this paper, clinical experience over the last years with BoNT in urological impaired patients will be illustrated. Moreover, this paper presents current data on the use of BoNT to treat pelvic floor disorders.
Surgical treatment of anal stenosis Giuseppe Brisinda; Serafino Vanella; Federica Cadeddu ...
世界胃肠病学杂志（英文版）,
2009, Letnik:
15, Številka:
16
Journal Article
R5; Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy.Anal stenosis represents a technical challenge in terms of surgical management. A ...Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment,both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements.Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.
Summary Carcinoma of the rectum is a common malignancy, especially in developed countries. The main stay of the therapy for rectal cancer is radical surgery. Total mesorectal excision has emerged as ...the surgical technique that can substantially reduce local recurrences. The laparoscopic approach does not seem to entail any oncologic disadvantages. Radiotherapy (RT) alone is capable of eradicating some localized rectal tumors while its effect on larger tumors is limited by normal tissue tolerance, tumor sensitivity and microscopic spread beyond the primary site. Preoperative chemoradiation has potential advantages. The rationale for combining cytotoxic agents and RT is based on the ability of some drugs to act as an enhancer of RT. Preoperative chemoradiation can potentially downstage tumors to facilitate surgery, reduce the risk of tumor seeding, problems with hypoxia which is increased postoperatively, allowing more optimal tumor cell kill for equivalent doses compared to postoperative radiotherapy. The addition of radiation to surgery has been successfully used in many disease sites. In the intraoperative radiotherapy (IOERT), a high dose to the area of highest risk for tumor cell persistence is delivered while dose-limiting structures such as small bowel, bladder, or ureters can be mechanically excluded. Our preliminary experience shows that laparoscopic rectal resection with IOERT is not only feasible, but associates oncologic radical treatment with important advantages of laparoscopic approach.
Open tension-free techniques of hernia repair using synthetic meshes are a well-accepted practice with an excellent patient comfort and a low recurrence rate. Otherwise, the influence of the ...resulting fibrosis on testicular perfusion is still unclear. In this study, the effect of prosthetic materials on testicular perfusion was evaluated using Duplex ultrasonography.
Twenty-four patients participated in this prospective study. A total of 26 procedures were performed under general anaesthesia. All patients underwent standardized scrotal ultrasound study and Duplex imaging preoperatively, 1, 3 and 9 months after the procedure. Scrotal volume, vein diameters and modifications of arterial blood flow, evaluated by the acceleration index (AI), of the funicular and peritesticular vessels were measured.
No statistically significant differences were found between preoperative and postoperative measurements which included testicular blood flow parameters and testicular volume. Moreover, in some cases, a testicular flow improvement was detected after the operation. Furthermore the side of the hernia and the position of the mesh slit (lateral or upper) to allow the passage of cord structures did not influence the results.
So far there is no evidence for a significant impairment of funicular structures after open hernia repair using tension free techniques.
The use of laparoscopic technique for management of symptomatic liver cysts is documented to be a feasible and safe procedure with proved symptomatic relief. In the present study, we reviewed the ...results of this approach in the management of symptomatic liver cysts.
Retrospective review of all patients with symptomatic liver cysts that were treated by laparoscopic fenestration in our department over a 3-year period from 1999 to 2001.
Ten patients were treated using a laparoscopic approach. All patients achieved short-term alleviation of symptoms and an uneventful postoperative course. The mean hospital stay was 3 days. Long-term follow-up (24 months) was available for all the patients. In all the patients, there was no clinical and radiographical recurrence.
The present study confirms that relief of symptoms can be achieved with the laparoscopic approach for non-parasitic liver cysts. Omental packing is not necessary to prevent recurrence of simple hepatic cysts.
PDF
