Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Trans-obturator colonic suspension during Altemeier's operation for full-thickness rectal prolapse: preliminary results with a new technique.

AIM: With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed. METHOD: Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure. RESULTS: There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies. CONCLUSION: The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrence.

[Inguinal tension-free hernioplasty performed by day-care surgery in a non-specialized hospital]. / Ernioplastica inguinale tension-free praticata in regime di Day Surgery in un ospedale non dedicato.

BACKGROUND: At present, as a result of the introduction of tension-free techniques, the general opinion is that the treatment of inguinal hernia needs day-care surgery. Nevertheless day-care surgery requires a specific organization of the hospital and of the territorial services, after the discharge of the patient. These facilities are not always available all over the country. The aim of this paper is to present the results of the treatment of inguinal hernia performed by day-care surgery in an unspecialized hospital. METHODS: From April 1999 to April 2000, 28 patients (25 M), median age 54 years (range 25-85), affected by inguinal hernia, underwent ernioplasty operation according to Trabucco technique, by only one skilled surgeon, in an unspecialized hospital. Five patients were affected by inguinal hernia of type I of Nyhus, 9 of type II, 10 of type IIIa and 4 of type IIIb. Twenty-five patients underwent spinal anaesthesia and 3 general anaesthesia due to failure of the previous one or for contraindications due to spine diseases or due to patient's request. All patients remained in the hospital the night after the operation. After discharge, patients were controlled in the outpatient ambulatory every other day for 10 days. After that, patients were required to submit to physical examination only if they were symptomatic. At present, average follow-up is of 18.1+/-6.3 months. RESULTS: The following unspecific complications prevalently due to spinal anaesthesia were observed: 2 (7.1%) acute urinary retentions, 1 (3.6%) headache, 1 (3.6%) acute hypotension, 2 (7.1%) feverets, 1 (3.6%) vomiting, and 1 (3.6%) influenza. The specific complications were: 2 (7.1%) transient neuralgias, 2 (7.1%) ecchimosis and 1 (3.6%) infection of the wound. Average intensity of postoperative pain (VAS) was of 2.8+/-1.2. The average abstention from work was of 12.5 days. Until now, any recurrence has been observed. CONCLUSIONS: In spite of the few cases, our results are similar to those of specialized hospitals organized for day-care surgery. Anyway, in the management of these patients in unspecialized hospitals, according to our opinion one night in the hospital after the operation is required for the easiness of the patient and of the surgeon.

Selection criteria and long-term results of surgery in symptomatic rectocele.

BACKGROUND: The aim of this study was to confirm some selection criteria for the transrectal repair of the anterior rectocele and to compare our surgical results with those reported in the literature. METHODS: From January 1992 to December 1999, 30 females (mean age 52.9 years, range 28-70 yrs) affected by anterior rectocele were prospectively evaluated with a standard questionnaire, clinical examination, proctosigmoidoscopy, colonic transit time, dynamic defecography, anal EMG, anal manometry. Then, they were submitted to transrectal repair of rectocele with anterior plication of the rectal muscular wall. Fourteen (46.6%) of them were also submitted to perineal levatorplasty. Patients were followed postoperatively (mean 25.7 months) with the same standard questionnaire, clinical examination, defecography, and manometry. Results were tested by Fisher's Exact text, Wilcoxon's test, and "t"-test. RESULTS: Rectal dyschezia, incomplete evacuation, digital help in defecating, mean stool frequency, and rectal bleeding significantly improved. After 3 months, 30% of patients had no complaints, 40% had only 1-2 episodes/month complaints, 13.3% had evacuation only using laxatives, and 16.6% were unchanged. Defecography showed a significant reduction of the rectocele in 70% of patients after 3 months. Manometric parameters were not significantly modified. Four (28.6%) out of 14 patients submitted to perineal levatorplasty complained of dyspareunia. CONCLUSIONS: Our surgical results were comparable with those reported in the literature, with more than 80% of successful outcome. Preoperative clinical data and defecography were confirmed to be basic parameters in selecting patients for surgery. Colonic transit time, anal EMG, and anorectal manometry demonstrated to be useful to recognize conditions as slow colonic transit time, peripheral denervation, and reduced voluntary contraction that could lead to a less satisfactory outcome after surgery, and might benefit with a postoperative perineal rehabilitation by biofeedback and anal electrostimulations. The perineal levatorplasty is not suitable in young females, due to the risk of dyspareunia.

Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse.

BACKGROUND: This randomized prospective study compared the outcome of circular hemorrhoidectomy according to the Hospital Leopold Bellan (HLB) technique (Paris) with Longo stapled circumferential mucosectomy (LSCM) in two homogeneous groups of patients affected by circular fourth-degree hemorrhoids with external mucosal prolapse. METHODS: From December 1996 to December 1999, 80 consecutive patients with fourth-degree hemorrhoids and external mucosal prolapse were randomly assigned to two groups. Forty patients (group A: 18 men, 22 women, mean age 50.5 years, range 21 to 82) underwent HLB hemorrhoidectomy, and 40 patients (group B: 15 men, 25 women, mean age 51.0 years, range 29 to 92) underwent LSCM. Before surgery, all patients were selected with a standard questionnaire for symptom evaluation, full proctological examination, flexible rectosigmoidoscopy, dynamic defecography, and anorectal manometry. No significant differences among the two groups were found. All patients were controlled with follow-up questionnaire and with clinical examination at 1, 2, 4, 12, and 54 weeks after the operation. A postoperative manometry was performed 3 months after surgery. RESULTS: The length of the operation was significantly lower in group B (25 +/- 3.1 SD versus 50 +/- 5.3 minutes, P <0.001). Mean hospital stay was 3 +/- 0.4 days in group A and 2 +/- 0.5 days in group B (P <0.01). Mean duration of inability to work was 8 +/- 0.9 days in group B and 15 +/- 1.4 days in group A (P <0.001). Postoperative pain was significantly lower in group B (P <0.001). Mean length of follow-up was 20 +/- 8.0 months in group A and 20 +/- 7.8 months in group B. Late complications were similar in the two groups, with 0%, at present, recurrence rate. CONCLUSIONS: Our results confirm that both operations are safe, easy to perform, and effective in the treatment of advanced hemorrhoids with external mucosal prolapse. However, the LSCM seems to be preferable owing to the fewer postoperative complications, easier postoperative management, and shorter time to return to work. A longer follow-up is required to confirm the true efficacy of this surgical method.

Which surgical approach for rectocele? A multicentric report from Italian coloproctologists.

The most effective surgical technique for rectocele has not yet been clearly established. A retrospective multicentric study was carried out to compare the long-term results of 3 endorectal techniques (Block, Sarles and stapled) and the perineal levatorplasty, alone and in association, in a series of patients with symptomatic rectocele. From January 1992 to December 1999, 2212 patients with defecation disorders were referred to 5 Italian coloproctology units. An anterior rectocele was clinically diagnosed in 1045 patients and confirmed with defecography. On the basis of clinical and radiological parameters, 317 patients (312 women; mean age, 52.4+/-20.1 years) were selected for surgery. Group 1 consisted of 141 patients (136 women; mean age, 50.4+/-18.8 years) who were submitted to endorectal operations. Group 2 consisted of 126 women (mean age, 52.5+/-19.7 years) who received perineal levatorplasty. Finally, 50 women (mean age, 54.3+/-21.9 years) in Group 3 received endorectal operations associated with perineal levatorplasty. A total of 269 patients were followed postoperatively (mean period, 24.2+/-3.1 months, 27.5+/-5.4 months and, 22.8+/-2.8 months, respectively) with the same questionnaire and clinical examination. Three months after surgery, a defecography examination and anorectal manometry were performed in 136 and 132 patients, respectively. Operative time, hospital stay and time to return to work were significantly higher in Group 3 (p<0.001). There was one death in Group 3 due to severe sepsis. Main postoperative complications were: in Group 1, hemorrhage (7.8%, all Sarles), dehiscence of the endorectal suture (5.0%, all Block), distal rectal stenosis (2.1%, 1 stapled, 2 block), and rectovaginal fistula (1.4%, all Sarles); in Group 2, delayed healing of the perineal wound (16.4%); in Group 3 delayed healing of the perineal wound (22.0%), hemorrhage (6%, all Sarles), dehiscence (4.0%), stenosis (2.0%). 17.3% of patients of Group 2 and 22.5% of Group 3 complained of dyspareunia. Postoperative defecography showed a complete absence of the rectocele in 44.1% of patients and reduction of size in the others, without significant differences among the three groups. Manometric pattern was not significantly modified by surgery. Significant symptoms recurred in 5.9% of the patients in Group 1, 6.4% in Group 2, and 5.0% in Group 3. Perineal levatorplasty did not significantly improve obstructed defecation, as it did not allow to excise the rectal mucosal prolapse, and was followed by an high incidence of delayed healing of the perineal wound and dyspareunia. Sarles procedure achieved better control of mucosal prolapse but carried a higher complication rate compared to the others. The association of the perineal levatorplasty with an endorectal technique required significantly longer operative time, and led to a longer hospital stay and time to return to work. In conclusion, the investigated techniques showed different patterns of postoperative complications: bleeding after Sarles, dehiscence after Block, dyspareunia after perineoplasty and fatal gangrene after stapled, but non of them showed a clear superiority over the others in term of clinical or functional results 2 years after surgery.

Laparotomic vs. laparoscopic rectopexy in complete rectal prolapse.

AIM: The aim of this study was to compare the functional and clinical results of laparotomic and laparoscopic rectopexy in 2 homogeneous groups of patients with complete rectal prolapse and fecal incontinence. METHODS: Between January 1989 and December 1997, twenty-three patients underwent abdominal rectopexy. Thirteen patients (group A, 12 females and 1 male, mean age 57.3, range 22-76 years), and 10 patients (group B, 10 females, mean age 52.3, range 26-70 years) were submitted respectively to either Wells laparotomic or laparoscopic rectopexy by the same surgical team using the same surgical technique and materials. Before the operation a detailed clinical history was collected, and the patients were studied by inspection and digital examination of the anorectum, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry and anal electromyography. After the operation all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. Mean follow-up was 37.1 (range 6-90) months in group A and 25.7 (range 6-49) months in group B. Values were compared by chi(2), Mann-Whitney U, and Wilcoxon tests as appropriate. Differences were considered significant at p < 0.05. RESULTS: In both groups dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. The basal pressure of the anal sphincter, squeezing pressure and rectoanal reflex improved without significance, and anal-perineal pain was not significantly reduced. In group B the postoperative hospital stay was lower than in group A, with a reduction in costs. CONCLUSION: Laparoscopic Wells rectopexy has the same clinical and functional results as laparotomic rectopexy, but with a shorter postoperative hospital stay and lower costs.

Surgical treatment of complete rectal prolapse: results of abdominal and perineal approaches.

This retrospective study reports the results of our 5-year experience in the diagnosis and treatment of rectal prolapse with fecal incontinence by the abdominal (laparotomy or laparoscopy) and perineal approaches. Twenty-five patients (group A; 22 women and 3 men; mean age 57.3 years; range 22-76 years) were operated on by the abdominal approach and ten (group B; 8 women and 2 men; mean age 68.9 years; range 58-84 years) by the perineal approach. All patients were evaluated by clinical examination, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography preparatory to surgery. In patients of group A, we performed an abdominal rectopexy in 19 cases (7 by laparoscopy) and in the remaining 6 cases, a sigmoid resection-rectopexy (3 of which were by laparoscopy). All patients of group B were treated by a perineal operation using Delorme's mucosectomy in 4 cases and Altemeier's rectosigmoidectomy with total perineoplasty in 6 cases. The mean follow-up was 38.8 months in group A and 25.7 months in group B. The postoperative complication rate was 8% (two cases) in group A, whereas no significant complications occurred in group B. Dyschezia and fecal incontinence improved significantly in both groups (P < 0.05 in group A and P < 0.005 in group B), whereas anoperineal pain was not significantly reduced. At 1-year follow-up, the recurrences rates were 8% in group A and 30% in group B. Rectopexy or resection-rectopexy proved to be a safe and effective procedure for external prolapse, without a discernible difference between the laparotomic and laparoscopic techniques. In selected cases, the perineal approach gives good results regarding fecal incontinence without complications, even if in these patients, the likelihood of recurrence is high.

Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results.

The aim of this retrospective study was to compare the functional and clinical results of laparoscopic rectopexy with those of the open technique in two similar groups of patients with complete rectal prolapse and fecal incontinence. Between November 1992 and June 1997, 21 patients underwent abdominal rectopexy. Thirteen patients (group A: 12 women and 1 man, mean age 52.9 years, range 28-70) and 8 patients (group B: 8 women, mean age 58.2 years, range 20-76) were submitted to Well's rectopexy by the open technique and the laparoscopic approach, respectively, without division of the lateral rectal ligaments. Assignment to each group was done randomly. Before the operation, a detailed clinical history was taken, and patients were studied with inspection and digital examination of the anorectum, proctosigmoidoscopy, determination of pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography. After the operation, all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. The mean follow-up time was 29.5 months (range 6-54) in group A and 25.7 months (range 8-45) in group B. Values were compared by chi-square, Mann-Whitney U, and Wilcoxon tests, as appropriate; differences were considered significant at p < 0.05. In both groups, dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. Basal pressure of anal sphincter, squeezing pressure, and rectoanal reflex improved without significance, whereas anoperineal pain was not significantly reduced. In group B, the postoperative hospital stay was shorter than in group A, with a marked reduction of costs. Laparoscopic Well's rectopexy has the same clinical and functional results as the open technique, with a shorter postoperative hospital stay and lower costs.

Endoscopic ultrasonography in the evaluation of leiomyoma and extramucosal cysts of the esophagus.

BACKGROUND/AIMS: Leiomyoma is the most common type of benign esophageal tumor, whereas extramucosal cysts of the esophagus are congenital anomalies frequently asymptomatic in the adult and in most cases detected incidentally on chest x-ray. It is worthwhile considering these conditions together, because they present similar diagnostic and surgical problems. Conventional imaging tests do not lead to a precise diagnosis. The purpose of this study was to evaluate the use of endoscopic ultrasonography in the diagnosis of, and planning of treatment modalities for, these conditions. METHODOLOGY: Fifteen patients with esophageal leiomyoma and seven patients with extramucosal esophageal cysts were studied with endoscopic ultrasonography using an Olympus GF- EU-M3 instrument with a 7.5-12 MHz echoprobe. In all patients, the results of endoscopic ultrasonography were compared with the histology of the resected specimens. RESULTS: The histology of the resected specimens confirmed the endosonographic diagnosis in all patients. No malignancy was found in any specimen. CONCLUSIONS: Endoscopic ultrasonography is very accurate in visualizing these lesions and differentiating cystic from solid submucosal esophageal masses; in addition, the test can establish the exact location of the mass in relation to the esophageal wall and mediastinum. Therefore, endoscopic ultrasonography has a great impact in confirming the diagnosis of leiomyoma and extramucosal cysts of the esophagus and facilitates therapeutic decision-making because of its capacity to clearly define the size, layer of the origin, and pattern of the mass.

Circular hemorrhoidectomy in advanced hemorrhoidal disease.

BACKGROUND/AIMS: Milligan-Morgan's hemorrhoidectomy has a high recurrence rate (> 10%) in patients with circular IV grade hemorrhoids. In such cases a circular hemorrhoidectomy with complete elimination of residual piles, and anoplasty might be more successful. The aim of this retrospective study was to compare the results of circular hemorrhoidectomy using the Hopital Leopold Bellan (HLB) technique (Paris) with the reported results of other techniques in patients with advanced hemorrhoidal disease. METHODOLOGY: From January 87 to December 96, 100 consecutive patients with circular IV grade hemorrhoids underwent radical hemorrhoidectomy. Mean hospital stay was 4 days (range 3-7). Patients were strictly controlled in the postoperative period and in cases of early fibrosis anal dilators were used. RESULTS: Eighty one percent of patients had a complete recovery. The recurrence rate was 4%. The cumulative rate of early and late complications was 34%. Early and late hemorrhages were more frequent than in traditional hemorrhoidectomy, while the incidence of anal stenosis was the same. CONCLUSIONS: The HLB operation is the best choice for patients with advanced circular hemorrhoids because of its radicality and good results. The postoperative morbidity of HLB hemorrhoidectomy is higher than traditional hemorrhoidectomy; nevertheless, all complications are tractable without extension of hospital stay.

Retroperitoneal fibrosis: unusual localization.

Six cases of retroperitoneal fibrosis, each with a different pathogenesis and unusual localization were observed from 1980 to 1996. Four patients had had previous surgery for a neoplasm, one patient had idiopathic retroperitoneal fibrosis, and the last patient was hardly classifiable due to the complexity of the clinical pattern. The mean survival in 3 patients with malignant retroperitoneal fibrosis was 7 months. Two patients treated with medical therapy are still alive and in good clinical condition. The aspecificity of the symptoms makes early diagnosis difficult. CT and NMR are essential procedures for differential diagnosis of abdominal masses. Histology differentiates benign from malignant retroperitoneal fibrosis. The choice between medical or surgical therapy depends on the general condition of each patient.

[The surgical correction of anterior rectocele. Our experience]. / Correzione chirurgica del rettocele anteriore. Nostra esperienza.

Rectocele, or namely the protrusion of the anterior wall of the rectum into the vaginal lumen following the collapse of the rectovaginal septum, is the most common anatomic alteration observed in patients suffering from defecation disorders. The surgical treatment of this pathology is still controversial, particularly in the choice of the surgical approach. From 1992 to 1994 10 patients suffering from low type, symptomatic anterior rectocele associated with intrarectal intussusception underwent muscular plastic surgery of the rectocele and anterior mucosectomy. The aim of this study was to evaluate whether surgical muscular plastic of the rectocele using a transanal approach associated with anterior mucosectomy represents in selected symptomatic patients, a rational and elective therapeutic option. In spite of the small number of patients and the short postoperative follow-up, the authors state that, on the basis of the results obtained, the surgical technique used in this clinical series significantly improves symptoms with a lower incidence of complications compared to the transvaginal approach.

[Video laparoscopic surgery and rectal prolapse. Our experience in rectopexy]. / Chirurgia videolaparoscopica e prolasso rettale. Nostra esperienza in tema di rettopessia.

BACKGROUND: Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is the evaluation of clinical and functional results in 4 patients submitted to a laparoscopy rectopexy according to Wells. METHODS: Four females (22-76, mean 53.7 years) affected from a total rectal prolapse with fecal incontinence underwent this procedure from 1993 through 1995. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, bio-feedback and electrostimulations, all patients have been re-evaluated by means of a clinical exam, anorectal manometry, defecography. RESULTS AND CONCLUSIONS: Preliminary results seem satisfactory and may allow to prefer this approach instead of the traditional open one.

[Treatment of acute symptoms of hemorrhoid disease with high-dose oral O-(beta-hydroxyethyl)-rutosides]. / Trattamento dei sintomi acuti della malattia emorroidaria con O-(beta-idrossietil)-rutosidea ad alte dosi per via orale.

The pharmacological treatment is widely used in the therapy of haemorrhoids. An efficient treatment is particularly useful in case of haemorrhoids of 2nd, 3rd and 4th degree, when phlogosis, oedema and pain are present. Forty patients were treated with either O-(beta-hydroxyethyl)-rutosides (4 g/day orally) or placebo in a double blind randomized comparative trial. The groups of treatment were homogeneous. O-(beta-hydroxyethyl)-rutosides induced a statistically significant reduction of pain and bleeding; placebo did not induce any significant improvement. Tolerability was good and similar for both treatments. It has never been necessary to stop treatment for side effects. The results obtained in this study confirm the usefulness on administering an oral treatment, and not only a local treatment, to patients with acute symptoms of haemorrhoids, both in case of intermittent treatment and in case it is used to prepare quickly the patient for surgery.

[Minor anal pathology. Suggestions for ambulatory and hospital treatment]. / La patologia anale minore. Suggerimenti al trattamento ambulatoriale e ospedaliero.

A series of cases of anorectal pathology treated at the out-patient level or after hospitalisation in the course of the last five years is reviewed. Deference is made to subjects with haemorrhoids operated according to Milligan-Morgan or Parks in accordance with varying indications, or treated cryosurgically as out-patients, patients with upper or lower transsphincteric perianal fistula treated by means of the lay-open technique or elastic tourniquet under general or local anaesthesia, patients with acute anal fissures treated by means of internal lateral sphincterotomy under local anaesthesia, and those with inveterate forms subjected to Arnous posterior leiomyotomy. From a critical assessment of the hospital and out-patient activities carried out suggestions and indications are drawn with regard to cases that must be treated in hospital and those for which outpatient management is correct.

[Cryogenic treatment of rectal tumors]. / Il trattamento criogeno dei tumori rettali.

10 patients with anal or rectal cancers were given liquid nitrogen cryogenic treatment. In 5 cases the treatment was given prior to abdominoperineal amputation of the rectum. The remaining 5 inoperable cases were given the cryogenic treatment alone, followed, in 3 cases by derivative colostomy. Histological reports on the removed tissues, carried out at different times after the cryogenic treatment, showed the effects of the treatment on the neoplasias and the surrounding tissues and showed the histological equivalent of possible local immunological processes. The thrombosis in the surrounding blood vessels appears to indicate the efficacity of cryogenic therapy in preventing the metastasis of neoplastic cells.

[Usefulness of the Doppler velocimetry in patients undergoing direct arterial surgery]. / Utilità della velocimetria Doppler nei pazienti sottoposti a chirurgia arteriosa diretta.

Two patients with an atypical and particularly troubled history, due to numerous direct and indirect interventions of vascular surgery, have been monitored in haemodynamic investigation using only Doppler velocimetry. The use of angiography would have necessitated other general anaesthesiae which would have further compromised the already critical conditions of the patients. Doppler velocimetry proved suitable for surgical indication in emergency situations. The value of an arteriograph under general anaesthesia is, however, unquestionable in cases of choice surgery.