Investigation of anal sphincter function following Mainz pouch type II urinary diversion after radical cystectomy.

PURPOSES: Our aim was to evaluate the anal sphincter function following cystectomy with urinary diversion of Mainz pouch II. METHODS: Seventy-six patients were involved in our survey, and the cohort was for two groups divided. The first group was a retrospective review of 40 patients with examination of the state of continence. Comparative examinations on anal sphincter function and the quality of life survey were carried out. The second group consisting of 15 patients underwent a prospective investigation including rectal manometry in both the pre- and postoperative periods. Measurements of resting anal sphincter pressure (RASP), maximal anal closing pressure (MACP) and the function of the recto anal inhibitions reflex were taken. RESULTS: In the first part of our investigation, 80% of the patients were considered as continent. There were no significant differences observed between RASP values in the cases of continent as well as of incontinent patients (79.2 ± 2 vs. 73.6 ± 68.4 mmHg, p = 0-53); however, the MACP values of the continent patients were significantly higher (204.3 ± 22.8 vs. 117.3 ± 14 mmHg, p = 0.001). In the course of the second experiment, both the RASP (86.3 ± 18.7 vs. 76.1 ± 13.9 mmHg p = 0.0049) and the MACP (232.2 ± 53.8 vs. 194.1 ± 74.5 mmHg, p = 0.0054) were detected as decreasing in the case of the incontinent group. CONCLUSIONS: A decrease in rectal sphincter function is responsible for incontinence following Mainz pouch type II diversion, and this dysfunction can be correlated with the surgery. Ureterosigmoideostomy is therefore considered as a useful method of urinary diversion only in selected cases with proven good sphincter function.

Septic complications after low anterior rectal resection--is diverting stoma still justified?

A retrospective study was designed to determine the effects of faecal diversion on the rate and severity of clinical anastomotic leaks after low anterior resection. The study explored the complications of stoma closure as well. During the period between 1 January 1995 and 30 July 2000, anterior rectal resection was performed on 249 patients with anastomoses created at a 6-cm or smaller distance to the dentate line. In 74 cases, the anastomosis was protected by loop ileostomy. The indications for creating a stoma were evaluated subjectively, by the operating surgeon. In 64 patients, the ileostoma was closed 3 months later. A 'clinical leak' after anterior resection was defined as an anastomotic insufficiency with clinically relevant consequences. The overall rate of anastomotic leak was 6.4 per cent; it was 5.1% (9/175) without and 9.4% (7/74) with a protective stoma. In 8 out of 9 patients, the anastomotic leak that had occurred without a protective stoma warranted laparatomy and defunctioning colostomy. Lavage and drainage of the peritoneal cavity and the presacral space were necessary in 6 out of these 8 cases- and furthermore, the deranged anastomosis had to be removed in 2 patients. Local management was successful in a single case only. Although relaparotomy entails long-term intensive care, all reoperated patients survived anastomotic leakage. Seven patients with a leak despite a protective did not require laparatomy; transanal drainage was appropriate in all cases. There were no fatalities in this group either. Only one fatal complication from suture leakage occurred after stoma-closure. Abdominal exploration was inevitable in almost all patients with a clinical anastomotic leak and without defunctioning stoma. By contrast, patients with anastomotic insufficiency despite a protective stoma were successfully managed without further intra-abdominal intervention. As shown by these results, faecal diversion undoubtedly mitigates the clinical consequences of anastomotic leaks, but cannot prevent its occurrence. When considering the cumulative risk of surgical complications associated with anterior resection, the complications of stoma-closure must also be taken into account. Our data confirm that a defunctioning stoma is beneficial for high-risk patients, who are unfit for a second abdominal procedure required to control suture leakage.

[Perspectives of laparoscopy in cardia and gastric surgery]. / A laparoszkópia útkeresése a cardiatáj és a gyomor sebészetében.

The authors have made 171 laparoscopic operations in the gastro-esophageal region during the past three and a half years. They have used the achievement of the minimal invasive surgery mainly in the treatment of functional diseases of the gastro-esophageal junction. Besides the hiatal reconstruction and antireflux procedures (142), endoscopic assisted cysto-gastrostomy (7), endoscopic assisted double-lifting gastric wall resection (5), cardiomyotomy (4), Graham suture of perforated duodenal ulcer (4) and enucleation of gastric wall leiomyoma (2) has been performed. There was no postoperative death, the rate of conversion was altogether 4.7% (8/171) while there was no need for reoperation in the early postoperative period.

[Possibilities in the preservation and restoration of anal continence]. / Az analis continentia megórzésének és helyreállításának lehetóségei.

The preservation of anal continence and the improvement of the patients' quality of life in general are primary objectives of colorectal surgery. Earlier the loss of the entire rectum, colon required a definitive stoma. This review describes surgical procedures designed to preserve anal continence. This paper also describes operative techniques designed to improve impaired sphincter function. Total extirpation of the mesorectum reduces local recurrence of rectal tumours. At the same time, this operation requires formation of the anastomosis low, at the level of the levator muscle. Low colorectal or coloanal anastomoses are associated with higher incidence of suture leakage and poor functional outcome. The distance between anastomosis and anal verge was less than 7 cm in 249 sphincter-sparing rectal resections performed during the examined 6-year period in our institute. Different techniques to perform anastomoses were applied, the prevalence of suture leakage and the functional results are analysed. Restorative proctocolectomy has dramatically improved the treatment of familial polyposis and ulcerative colitis with rectal involvement. Although proctocolectomy is necessary to cure the disease, acceptable faecal continence can be achieved by creating ileoanal anastomosis with ileal reservoir. We discuss our results after 43 operations. Weakness of the sphincter apparatus is the most common cause of continence problems. Occasionally, the sphincter is no longer suitable for reconstruction because of extensive damage or denervation. In such cases, the levator muscles or--if neither these are of acceptable quality--the gluteus maximus muscle can be used to repair the external sphincter. Anterior levator plasty involves tightening the levator plate by suturing its arches together between the rectum and the vagina. This procedure enhances the resistance of the sphincter barrier primarily by increasing functional sphincter length. The functional outcome of this procedure was acceptable in two-thirds of the 52 operations. Post anal repair was performed only in 3 patients. This method comprises reinforcing the levator plate through an access between the external and the internal sphincters. When the levator plate is unsuitable, bilateral gluteus plasty can be performed to increase the strength of sphincter muscles. As the gluteus is a striated muscle it can improve only the of the external sphincter function. Therefore this procedure can restore acceptable continence to hard stool only. This is demonstrated by our clinical experience obtained in 10 patients.

Late epigastric incisional hernias following laparoscopic cholecystectomy.

By the introduction of laparoscopic cholecystectomy a new "gold standard" procedure became a routinely performed operation in the field of biliary tract surgery. Thus, the incision related early and late complications are thought to diminish, especially the formation of incisional hernias. Five patients had been referred to our department suffering from chronic incisional hernias following laparoscopic cholecystectomy. All of the hernias were located to the site of the epigastric trocar. The contents of the hernias proved to be omentum. The documentation's of the laparoscopic cholecystectomies revealed the extraction of thick walled gallbladders that contain large stones, and the wounds through which the extraction was performed had not been closed. Taking into consideration the fact of the "Chimney Effect" caused by the desufflation of the pneumoperitoneum at the end of the laparoscopic operation, bowel or omentum can easily escape through the relatively large wound formed during the extraction of the gallbladder, resulting in the formation of incisional hernias. This can be avoided by the complete desufflation and the prompt closure of the wound.