Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome.

BACKGROUND: This prospective multicentre study assessed the safety and effectiveness of stapled transanal rectal resection (STARR) for treatment of obstructive defaecation syndrome (ODS). METHODS: Between February 2001 and June 2006, 104 patients diagnosed with ODS were treated with STARR. Follow-up was scheduled for 1, 3 and 6 months after surgery, and annually thereafter. Variables related to the patient, surgical technique and outcome were analysed. RESULTS: Mean operating time was 46.7 min. Haemorrhage at the staple line occurred in 55 patients (52.9 per cent). Three patients required surgical revision in the first 48 h owing to persistent bleeding. The median postoperative pain score was 2.4 on a scale from 1 to 10. Mean hospital stay was 2.2 days. The mean constipation score improved from 13.5 before surgery to 5.1 at 1-year follow-up (P = 0.006). Twenty-three patients reported faecal incontinence at 4 weeks after surgery, but only nine still had minor residual incontinence by 1 year. At a median follow-up of 26 (range 12-72) months, ODS had recurred or persisted radiologically and/or clinically in 11 patients. CONCLUSION: STARR is associated with low morbidity and a short hospital stay, and is an effective alternative treatment for ODS.

[Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results]. / Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares.

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baseline Wexner-Cleveland scale scores and ability to delay defecation were compared to results after one year with SRN. The initial study of patients included history taking, general examination, anal ultrasonography, and manometry, and a three-week diary of continence and quality of life specific for FI was used. Before SRN the mean baseline Wexner-Cleveland score was 15.00 +/- 1.81, and 62.50% of patients could only delay defecation for less than a minute. After a year with NRS the mean Wexner-Cleveland score was 4.87 +/- 2.54 (p = 0.0031), and 75.01% of patients could delay defecation above fifteen minutes (p = 0.0018). We also describe the surgical technique and its indications, and finally review the various therapeutical options for FI and show our algorithm for this condition. SRN is an effective technique for the treatment of FI in properly selected patients with no response to medical therapies (including biofeedback) or anatomic correction (sphincteroplasty), with efficacy, little morbidity, and a short hospital stay.

Is anal endosonography useful in the study of recurrent complex fistula-in-ano?

INTRODUCTION: performing anal endosonography in complex fistula-in-ano allows us to design a personalized surgical strategy in each case, thereby improving results. However, there are doubts in the literature as to its utility in recurrent complex fistulas. The aim of this study was to compare the utility of anal ultrasonography in the study of primary versus recurrent complex fistula-in-ano. PATIENTS AND METHOD: prospective study of patients diagnosed and treated for complex fistula-in-ano. Physical examination and anal ultrasonography provided data on primary track, internal opening, horseshoe extension and the presence of secondary tracks or cavities in a protocol designed specifically for the study. These assessments were subsequently contrasted with operative findings. RESULTS: we included 35 patients, 19 (54.3%) with primary complex anal fistulas and 16 (45.7%) with recurrent fistulas. According to the operative findings, fistulas were classified as high transsphincteric in 28 patients (80%), suprasphincteric in 6 (17.1%) and extrasphincteric in one patient (2.9%), with no differences between groups. Physical examination correctly classified 28 of the 35 fistulous tracks, in contrast to the 32 (91.4%) correctly described on ultrasonography (80%). We did not find any statistically significant differences between the primary and the recurrent fistula groups with regard to sensibility, positive predictive value and accuracy of the anal ultrasonography for any of the parameters studied. CONCLUSION: the accuracy of anal ultrasonography does not decrease in recurrent complex fistula-in-ano.

[Treatment of proctalgia fugax with botulinum toxin: results in 5 patients]. / Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes.

INTRODUCTION: Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. PATIENTS AND METHODS: Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. RESULTS: Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. CONCLUSION: Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax.

[Manometric factors associated with recurrence in botulinum toxin treatment for chronic anal fissure]. / Factores manométricos pronósticos de recurrencia en el tratamiento de la fisura anal crónica con toxina botulínica.

INTRODUCTION AND AIM: To evaluate the effectiveness of botulinum toxin in the treatment of chronic anal fissure after long-term follow-up and establish the manometric factors related to recurrence. PATIENTS AND METHOD: We performed a prospective study in 50 consecutive patients with chronic anal fissure who were treated with 25 U botulinum toxin injected into the internal sphincter. Clinical and manometric parameters were recorded until the fourth year of follow-up. RESULTS: There was a tendency to progressive recurrence over time (54% at 4 years) associated with manometric factors indicating hyperexcitability of the internal anal sphincter (persistently elevated mean resting pressure, percentage of time with slow waves, and number of patients or percentage of time with ultra-slow waves after treatment). CONCLUSIONS: Treatment of chronic anal fissure with botulinum toxin leads to long-term cure in less than 50% of patients. In patients with manometric factors related to recurrence, this treatment is insufficient for definitive cure.

Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study.

BACKGROUND: Chronic anal fissure is one of the most frequent proctological disorders in Western populations. Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal. MATERIAL AND METHODS: We carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery. RESULTS: Early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred. Fissures recurred in nine patients (7.5%) within one year. The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months. The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant. CONCLUSIONS: Open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques. It may therefore be considered an effective treatment for chronic anal fissure.

Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse.

PURPOSE: to assess the effectiveness of ambulatory rubber band ligation (RBL) in the treatment of symptomatic internal haemorrhoids and to identify factors related to relapse. PATIENTS AND METHODS: prospective study of 232 patients treated with rubber band ligation for symptomatic haemorrhoids (grade I-III or grade IV with severe contraindication for surgery) from November 1996 to November 2000 at the outpatient clinic. Ligation was performed with a Stille AB (Comedic) ligator and suction pump, placing 1-3 bands per session and with up to three sessions per patient. Effectiveness of treatment was defined as the absence of symptoms and was confirmed by anoscopy by checking the residual scar after the cushions' detachment. Categorical variables were compared using the shi-squared test, whereas Student's t-test was used for continuous variables. Logistic regression was employed to identify clinical factors related to relapse. RESULTS: a total of 331 bands were placed during 235 sessions in the 163 patients who completed follow-up (70%). Mean age was 45.6 years, with males accounting for 64.4%. Most patients (86.5%) had grade II or grade III haemorrhoids. Overall morbidity was 6%. The most frequent complications were rectal tenesmus (11%), slight or mild anal pain (7.4%), dysuria (4.3%) and transient anal bleeding (3.7%). The treatment was effective in 86% of patients after a mean follow-up of 32 months. Efficacy was high for grades I and II (100% and 97.4% ) but decreased for grade III (69.8%; p<0.001) and grade IV (0%; p<0.001). Most relapses occurred within the first 24 months (87%) and were not significantly related to age, gender, duration of symptoms, itching, bleeding, pain, tenesmus or bowel habit, but were significantly related to the presence of prolapse and its grade (p<0.001), and to the involvement of left posterior, right lateral and anterior pedicles (p<0.05). CONCLUSIONS: ambulatory RBL is a safe and effective treatment for grade I, II and III symptomatic haemorrhoids, and is associated with low morbidity. Recurrence is uncommon and occurs mainly within the first 24 months, being related to the presence and grade of prolapse as well as to its location, but bears little relation to the rest of factors analysed.

Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula track treatment.

BACKGROUND AND AIMS: Anal abscess is a frequent acute proctological disorder and whether the underlying fistula should be treated at the same time when the abscess is drained remains controversial. We examined indications for drainage alone versus drainage plus fistulotomy in terms of recurrence and continence. PATIENTS AND METHODS: We carried out a randomized prospective study of 200 consecutive patients with anal abscess. One group received drainage alone, while in the other group drainage plus fistulotomy was performed when a subcutaneous-mucosa, low transsphincteral, or intersphincteral fistula was found. Delayed progressive fistulotomy with suture threads was performed in cases of high transsphincteric or suprasphincteric fistula. RESULTS: The internal opening of the fistula track was found in 83% of the patients. The recurrence rate was related to the surgical technique employed: 29% in the group with drainage alone and 5% in the group for which treatment of the fistula track was attempted. The incontinence rate was also related to the surgical option. In those receiving drainage and treatment of the fistula track incontinence was restricted mostly to patients with delayed fistulotomy (36.7%), compared to 2.8% of patients when simple fistulotomy was performed. There was no incontinence in the drainage alone group. CONCLUSION: Drainage of anal abscess with fistulotomy can be safely performed in cases of subcutaneous, intersphincteral, or low transsphincteral fistulae with a minimal recurrence rate. However, drainage alone and posterior treatment of the fistula track is recommended for high transsphincteral or suprasphincteral fistulae.