Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016).

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

[Rectal pocket syndrome after stapled haemorrhoidopexy]. / Rectal-Pocket-Syndrom nach Stapler-Hämorrhoidopexie.

We report the case of a 41-year-old female patient who presented in the emergency department with recurrent pain in the lower abdomen 3 years after haemorrhoidopexy (Longo's procedure). At clinical examination a space-occupying mass between the rectum and the vagina was present which was identified as a stool-loaded diverticulum of the rectum by magnetic resonance imaging. Using a perineal approach the diverticulum could be excised at its base and the defect of the mucosa was closed transanally with sutures. A diverticulum of the rectum is a rare complication (2.5%) after stapled haemorrhoidopexy. In the diagnostic of complications after Longo's haemorroidopexy the MRI constitutes an excellent auxiliary modality.

[Urethral fistula due to Crohn's disease: case report of successful conservative management]. / Ausgedehnte bulbäre Harnröhrenfistel bei Morbus Crohn: Fallbericht einer erfolgreichen konservativen Therapie.

We report a case of a recto-urethral fistula in Crohn's disease. In our case, suprapubic cystostomy, ciprofloxacin, metronidazole, and azathioprine led to complete remission. Recto-urethral fistulas due to Crohn's disease are very uncommon. Pneumaturia, faecaluria, urinary tract infection, dysuria, and urethral discharge are the most common complaints. After complete diagnostics, immunosuppressive therapy in complicated Crohn's disease is of increasing importance. It is recommended to continue treatment after healing to prevent further complications.

Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer.

BACKGROUND: Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer. METHODS: Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups. RESULTS: Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0.402 for major and P = 0.691 for minor complications). Median number of lymph nodes removed was 7 (range 1-22) for EPMR and 11 (range 2-36) for LAR (P = 0.132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence. CONCLUSION: EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

[New concept in the treatment of the pilonidal sinus]. / Neues Therapiekonzept für den Sinus pilonidalis.

Symptomatic pilonidal sinus is characterized by an acute or a chronic inflammation. The surgical management of symptomatic pilonidal sinus is still a matter of discussion and no clear recommendations exists. On the basis of results from published studies and our own experience we developed a new two step therapy concept: Infected pilonidal were first drained by a small excision of the abscess (if possible in local anesthesia) followed by a close fistula excision. With this approach we were able to achieve a low morbidity and a high healing rate. In the case of extensive fistulating pilonidal sinus or recurrent disease we recommend radical excision and primary reconstructive flap what showed good aesthetic results.

Outcome and cost analysis of sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) may be successful in treating incapacitating faecal incontinence. The technique is expensive, and no cost analysis is currently available. The aim of this study was to assess clinical outcome and analyse cost-effectiveness. METHODS: Thirty-six consecutive patients underwent a two-stage SNS procedure. Outcome parameters and real costs were assessed prospectively. RESULTS: SNS was tested successfully in 33 of 36 patients, and 31 patients were stimulated permanently. In the first stage, eight of 36 patients reported minor complications (pain, infection or electrode dislocation), resulting in a cost of euro 4053 (range euro 2838-7273) per patient. For the second stage (permanent stimulation), eight of 33 patients had an infection, pain or loss of effectiveness, resulting in a cost of euro 11,292 (range euro 7406-20,274) per patient. Estimated costs for further follow-up were euro 997 per year. The 5-year cumulative cost for SNS was euro 22,150 per patient, compared with euro 33,996 for colostomy, euro 31,590 for dynamic graciloplasty and euro 3234 for conservative treatment. CONCLUSION: SNS is a highly cost-effective treatment for faecal incontinence. Options for further reduction of SNS costs include strict patient selection, treatment in an outpatient setting and using cheaper devices.

Video-assisted sacral nerve stimulation.

BACKGROUND: Sacral nerve simulation (SNS) is an accepted therapy for patients with urinary or bowel dysfunction. However, infection rates are as high as 20% and can result in removal of the expensive device. We present a new video-assisted technique minimizing the risk of infection. METHODS: Between April and July 2005, six consecutive women of median age 68 years (range, 60-74), with faecal incontinence (4 patients) and idiopathic constipation (2 patients) underwent video-assisted electrode implantation for SNS. The motor response of the pelvic floor during percutaneous nerve evaluation and implantation of the permanent lead was monitored by a video optic (same as that normally used for laparoscopic or endoscopic procedures) placed between the legs of the patients. The video optic and the perianal area were completely covered with drapes, separating them from the operating field. RESULTS: All but one screening was successful, and no wound infections at the electrode or at the pocket of the stimulator were noted (mean postoperative follow-up, 8 weeks). CONCLUSIONS: With the use of a video optic, the anus and the implantation site can be completely separated and contamination during the operation becomes unlikely. Furthermore, the response of the pelvic floor to the stimulation is better visualized. We routinely recommend the use of video equipment for SNS electrode implantation.

External pelvic rectal suspension (the Express procedure) for full-thickness rectal prolapse: evolution of a new technique.

OBJECTIVE: The Délorme's operation for rectal prolapse is a safe procedure but has a high recurrence rate. We aimed to develop an operation akin to it, but designed to reduce this deficit. PATIENTS AND METHODS: Thirty-one consecutive patients with rectal prolapse were included in the study. Initially, a conventional Délorme's procedure was performed and sutures or strips of Gore-Tex were attached circumferentially to the apex of the prolapse, tunneled subcutaneously, and anchored to the external surface of the pelvis. Subsequently, the procedure was modified. Acellular porcine collagen strips were used and buried within the apex without plication of the denuded rectal musculature. Patients were formally assessed preoperatively and four months postoperatively by symptom and quality of life questionnaires and subsequently by regular clinical review. RESULTS: In the Gore-Tex group (N = 11; males:females = 10:1; mean age, 61 years) three patients underwent suture repair and eight had strip fixation. All suture repairs developed sepsis and one patient had a recurrence. Seven of the strip fixations (88 percent) developed sepsis that resulted in implant extrusion. There was one full-thickness and one mucosal recurrence after a median follow-up of 25 months. In the collagen group (N = 20; males:females = 2:18; mean age, 63 years), sepsis occurred in four patients, requiring surgical intervention in one patient (5 percent) (cf Gore-Tex group, P = 0.002). There was one mucosal and three full-thickness (15 percent) recurrences after a median follow-up of 14 months (cf Gore-Tex group, P = not significant). Significant improvements in symptom and quality of life scores were recorded in both groups at four months. CONCLUSION: A new, minimally invasive perineal procedure for rectal prolapse has been developed and initial data testify to its relative safety provided collagen is used. It remains to be seen whether long-term recurrence rates will be lower than those of conventional perineal procedures.

[Laparoscopy resection for colon cancer. The new standard?]. / Wird die laparoskopische Resektion des Kolonkarzinoms zum neuen Standard?

Surgical resection is the primary treatment for colon cancer. The introduction and acceptance of laparoscopic colectomy for cancer has been gradual for a number of reasons including the fact that it is technically challenging, has less than dramatic patient benefits, and perhaps most significantly it could theoretically represent a compromise as an oncologic procedure. Evidence suggests that laparoscopic colectomy for colon cancer is safe, feasible, and an oncologic adequate resection can be performed with acceptable operative times and conversion rates. It may result in improved outcomes when performed by experienced surgeons. The recently published results from the largest and first prospective randomized trial with sufficient statistical power have shown that laparoscopic colectomy is as effective as open colectomy in preventing recurrence and death from colon cancer. In experienced hands, laparoscopic colectomy for the cure of colorectal cancer appears to be equivalent to open surgery and may become standard in selected patients.

[New modalities and concepts in the treatment of hemorrhoids]. / Neues in der differenzierten Behandlung des Hämorrhoidalleidens.

The surgical treatment of haemorrhoids has significantly changed by introducing new techniques in the last years. Nowadays, low grade haemorrhoids, grade II and III, are easily and painfree treatable by a minimal invasive, Doppler transducer guided ligation of the haemorrhoidal arteries. In cases of circular protruding haemorrhoids, grade III and IV; the stapled mucosectomy described by Longo is also a new effective treatment. Both procedures can be performed for an outpatient or with short hospital stay and allows patients to return to work earlier compared to conventional techniques. Additionally, due to the new techniques the treatment of haemorrhoids is less painful and has increased patients' satisfaction. Therefore, the traditional haemorrhoidectomy, the Milligan-Morgan or the Ferguson procedure, has become less common and is only performed in a few special indications.

Experimental model of continent colostomy using rectus abdominis neosphincteroplasty.

BACKGROUND: Use of dynamic myoplasty to create a continent stoma has produced promising results, but long-term stoma continence has not been achieved. The aim of the study was to establish and test a new model. METHODS: Three types of dynamic rectus abdominis sphincteroplasty around a colostomy and two conditioning protocols were tested in ten domestic pigs. Continence was assessed by means of conventional defaecography and neosphincter manometry after 8 and 12 weeks. The neosphincter muscle was studied histologically to assess the transformation of muscle type. RESULTS: Use of a distal rectus muscle sling surrounding the stoma by 270 degrees with a low-frequency conditioning protocol achieved a continent colostomy for more than 12 h on each of 5 consecutive days. The neosphincter had a 40-mm high-pressure segment with mean pressure of 74 (range 67-82) mmHg. The proportion of type I muscle fibres increased from 38 (range 32-42) to 74 (range 66-78) per cent after 12 weeks of conditioning. CONCLUSION: This pilot study demonstrated the feasibility of a continent stoma in an animal model with a dynamic rectus neosphincter. Long-term results should be confirmed in a larger series before use in humans can be considered.

[Prospective assessment of the learning curve and safety of stapler hemorrhoidectomy]. / Prospektive Erfassung von Lernkurve und Sicherheit der Stapler-Hämorrhoidektomie.

INTRODUCTION: Stapled haemorrhoidectomy (SH) is a recently introduced procedure for the surgical excision of haemorrhoids. Actually, there is only limited information concerning the impact of the learning curve, complication rates and long-term results. Therefore, a prospective single-center study was performed with special regard to the learning curve and clinical safety of SH. METHODS: The data of 61 SH performed between March 1999 and May 2001 were analyzed. Operating times, complication rates and outcome results were prospectively recorded and then correlated to the surgical experience of the operating team. Postoperative pain was measured using the visual analogue scale (VAS). Sphincter lesions represented by the patient's incontinence and muscle defects were analyzed by using Williams incontinence score and histological examination of the resected specimen. Clinical follow-up studies were performed three and twelve weeks postoperatively. RESULTS: There were 18 patients with grade II haemorrhoids, 38 patients with grade III haemorrhoids, and five patients with grade IV haemorrhoids. Both, operating times and complication rates decreased with more surgical experience. The mean pain score during the first four postoperative days was 1.9 (range 0-8). Mean hospital stay and mean convalescence time were 1.7 days (range 1-5 days) and 10 days (range 1-31 days), respectively. Incontinence scores revealed only minor differences between pre- and postoperative values. CONCLUSIONS: SH represents a safe and effective new treatment modality for symptomatic haemorrhoids. Meticulous surgical technique and experience are mandatory to achieve excellent clinical results, e.g., reduced postoperative pain, shortened hospital stay and convalescence. We adopted SH to our surgical armamentarium for the treatment of haemorrhoids grade III and recurrent haemorrhoids.

[Fecal incontinence: therapy of congenital sphincter dysplasia in adulthood--a case report]. / Stuhlinkontinenz: Therapie der kongenitalen Sphinkterdysplasie im Erwachsenenalter--ein Fallbeispiel.

The dynamic graciloplasty has gained acceptance in the therapy of intractable fecal incontinence. With a success-rate of 60 to 80%, the dynamic graciloplasty is a good alternative towards a permanent colostomy for individual cases. Furthermore, adults suffering from congenital anal atresia may be well treated by this therapy as described in this case. Following surgery, an accurate follow-up is inevitable in these patients, including training of neosphincter control. After 8 to 12 weeks the training-process of the neosphincter-control should be finished. At this point of time the patient will have obtained defecation-control and should be able to execute voluntary defecations.

[Contact litholysis of gallstones with methyl tert-butyl ether in risk patients--a case report]. / Kontaktlitholyse von Gallensteinen mit Methyltertbutyläther bei Risikopatienten--Eine Fallbeschreibung.

INTRODUCTION: Before laparoscopic cholecystectomy and endoscopic therapy became gold standard the nonsurgical treatment of symptomatic cholelithiasis, i.e. contact dissolution using methyl-tert-butyl ether (MTBE), was a valuable alternative. Even nowadays, stone dissolution may be helpful in critically ill patients. CASE REPORT: A 85-year-old man admitted in poor general condition due to cholangitis with septicemia following endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and partial stone removement because of impending perforation of the gallbladder empyema was treated by a percutaneous cholecystostomy with a pigtail catheter. After clinical improvement a successful contact dissolution was initiated by irrigation of the common bile duct and gallbladder with MTBE. The patient is asymptomatic three months after treatment. DISCUSSION: Symptomatic cholelithiasis is usually treated by endoscopic techniques. Percutaneous cholecystostomy in association with contact litholysis using MTBE is an effective treatment in patients who can not be operated due to critical conditions. The success rate in case of cholesterol stones averages 70 to 95% depending on number and size of stones. It is a non-invasive treatment with few side effects. CONCLUSION: In high-risk patients with severe cholecystitis, percutaneous catheter cholecystostomy combined with contact litholysis using MTBE is a successful, safe, and cheap treatment.

Is growth influencing diameter and function of laparoscopic TESA hepaticojejunostomy? A comparison of adult minipigs and juvenile domestic swine.

Current treatment of obstructive jaundice includes endoscopic stenting and open surgical bypass. To combine the advantages of surgical bypass with the minimal invasive approach of endoscopic stenting we developed a laparoscopic technique, transient endoluminally stented anastomosis (TESA). As shown previously, small-diameter anastomoses (e.g., hepaticojejunostomy) by TESA technique can be performed reliably in growing domestic swine. This further preclinical trial was designed to exclude growth of the animals as the main reason for these excellent results. After ligation of the common bile duct, a laparoscopic Roux-en-y hepaticojejunostomy was performed 7 days later by TESA with a reabsorbable radiopaque polyglycolic acid stent. In group A (n = 7) growing domestic pigs and in group B (n = 5) adult minipigs were operated on. Laboratory parameters were controlled weekly. Stent degradation was followed by weekly abdominal x-ray. At necropsy 6 months after surgery, cholangiography was performed and the anastomoses were measured. Mean weight gain was 140.7 +/- 10.9 kg in domestic pigs versus 5.8 +/- 1.6 kg in minipigs. Cholestasis normalized within 7 days postoperatively. Duration of stenting was not significantly different between groups. Cholangiography at necropsy showed immediate runoff through the anastomoses in both groups. The diameter of the anastomosis was 4.7 +/- 0.5 mm in group A versus 3.0 +/- 0.4 mm in group B (p = 0.03). In conclusion, functionality of the small-diameter TESA hepaticojejunostomy is not related to age and growing factors in pigs, justifying its application in human as the next step of investigation.