Functional disorders of the pelvic floor. Recommendations of the Polish Coloproctology Club of the Scientific Society.

Zaburzenia czynnociowe dna miednicy s zjawiskiem zoonym zalenym od ubytkw anatomicznych w ukadzie powiziowo-miniowym oraz od stanu ich unerwienia i jakoci tkanki cznej. Maj one rozmaite postacie i lokalizacje. Od ich konfiguracji zaley obraz kliniczny zaburze czynnociowych w tym obnianie dna miednicy, wypadanie narzdu rodnego, odbytnicy, rectocele, enterocele i cystocele. Rekomendacje dotycz zasad diagnostycznych oraz kompleksowego postepowania terapeutycznego. Istot leczenia chirurgicznego jest odbudowa architektoniki tkanek oporowych dna miednicy technikami beznapiciowymi z uyciem materiaw protetycznych. Umoliwia to przeprowadzenie skutecznego umocowania obniajcych si struktur i wypadajcych narzdw.

Pancreaticopleural Fistula as a Rare Cause of Both-Sided Pleural Effusion.

A pancreaticopleural fistula is a rare cause of pleural effusion. It is a complication of chronic or acute pancreatitis. It is rarely formed to the right or both pleural cavities. Diagnosis and proper treatment often turn out to be difficult and require the cooperation of a multidisciplinary team. The authors present the case of a 59-year-old patient treated for recurrent pleural effusion of unknown origin, first to the left and then to the right pleural cavity. After many months of treatment, the diagnosis of a pancreaticopleural fistula was made. The patient underwent surgery, which finally led to a successful complete recovery. Pancreaticopleural fistula should always be considered in patients with pleural effusion of unknown origin.

Prosthetic materials for treating posterior vaginal wall prolapse and rectocele - own experience.

OBJECTIVES: This report describes results of posterior vaginal wall prolapse and rectocele treatment performing tension free reconstruction method with polypropylene mesh implantation. MATERIAL AND METHODS: In years 2001 to 20015, 71 female patients in age of 42-82 years were surgically treated. Besides difficult emptying they complained of feeling of heaviness in the pelvis (38%) and dyspareunia (16.9%). Defecography and magnetic resonance proved the presence of rectocele in 84.5%, enterocele in 38%, descending perineum in 28.2%, genital organ prolapse in 23.9%, and rectal prolapse in 22.5% cases. 37 patients with defects of low location have undergone implantation of prosthetic material from vaginal approach. In cases of high location and genital organ prolapse abdominal approach was done. RESULTS: Permanent reconstruction of the rectovaginal septum has been achieved in 70 patients (98%). Symptoms of dyschesia, pelvic plain, heavy straining were persisted in 4 patients (10.3%). 3 cases of mash erosions were diagnosed. One patient was reoperated. Among 6 other patients who needed futher surgical treatment only one was reoperated because of vaginal prolapse. 81.7% of patients was satisfied with their treatment. CONCLUSION: Using prosthetic materials in pelvic floor defects treatment is characterized by high efficacy and low complication percentage.

Diagnostic importance of faecal markers in long-term monitoring of anti-TNF-α therapy in primary responders with Crohn's disease.

INTRODUCTION: Monitoring the response to biological treatment in Crohn's disease (CD) is a very important element of the therapeutic optimisation. AIM: To evaluate the usefulness of measuring calprotectin, lactoferrin, and myeloperoxidase in stool as markers of long-term clinical and endoscopic response to anti-tumour necrosis factor α (anti-TNF) treatment in CD. MATERIAL AND METHODS: The studied group consisted of 35 CD patients treated with anti-TNF-α antibodies. Clinical activity was evaluated using Crohn's Disease Activity Index (CDAI), and the exacerbation of endoscopic changes was evaluated using a Simple Endoscopic Score for Crohn's Disease (SES-CD). The concentration of calprotectin, lactoferrin, and myeloperoxidase was measured using the ELISA method. All measurements were performed three times - before, after 3 months, and after a year of therapy. RESULTS: During anti-TNF treatment the concentrations of all measured faecal markers decreased significantly in relation to baseline values. We observed a significant correlation at all time-points: before the therapy, after 3 months, and 12 months after starting the therapy, between the concentration of calprotectin and SES-CD, calprotectin and CDAI, as well as between lactoferrin and SES-CD, and lactoferrin and CDAI. Myeloperoxidase correlated with both SES-CD and CDAI only after 1 year of treatment. CONCLUSIONS: Faecal calprotectin and lactoferrin are valuable markers of clinical and endoscopic activity of CD in patients treated with anti-TNF antibodies. They are useful in monitoring the response to treatment. The usefulness of myeloperoxidase in this respect remains controversial.

Anatomical and functional results of a modified sacral perineocolporectopexy for extreme forms of complex pelvic organs prolapse--own experience.

OBJECTIVES: Anatomical and functional results of a modified sacral perineocolporectopexy for extreme forms of complex pelvic organs prolapse. MATERIAL AND METHODS: Between 2005 and 2010, 10 women aged 47-75 years were treated by abdomino-perineal implantation of polypropylene mesh for modified sacral perineocolporectopexy and subsequently followed-up. They were suffering from enterocele (9 pts), genital prolapse (8 pts), descending perineum (5 pts), rectal prolapse (4 pts), rectocele (3 pts). Five women were incontinent (mean Wexner: 9) and six had incomplete rectal evacuation. Defecography revealed enterocele III°(5 pts) and II°(4 pts). MR designed descending perineum in 5 pts (mean: 3.8 cm). RESULTS: Permanent reconstruction of the pelvic floor and remission of organs prolapse was achieved at 12-months follow-up in all except 1 patient. There were 2 small vaginal erosions of the mesh and 1 haematoma within the pelvic floor Improvement at rectal emptying was found in 4 patients, feeling of pelvic heaviness in 6 patients, dyspareunia in 3 patients. Mean incontinence score decreased from 9 to 4. CONCLUSIONS: 1. Modified sacral perineocolporectopexy is effective in the treatment of complex pelvic floor anatomical defects and organ prolapse. 2. Improvements in rectal emptying, pelvic feeling of heaviness and dyspareunia have been achieved. 3. The implant tolerance was good and the complications rate was law.

Buschke - Loewenstein tumor resection with simultaneous reconstruction of extensive tissue losses: case report.

BACKGROUND: Giant condyloma acuminatum or Buschke - Loewenstein tumor is a very rare disease usually located in the genital, anorectal, and perianal regions. It is locally invasive but in mostly cases displays a benign cytology on preoperative tissue sampling. Because of its low incidence little is known about treatment outcomes. Complete surgical excision is the treatment of choice. Different surgical methods have been applied to reach curability. To our knowledge such an advanced sized tumors in this localization has only been reported few times before with different surgical techniques being applied. CASE PRESENTATION: We describe a case of 56 years old female with 20 years persisting condyloma acuminatum progressing to a very huge dimensions perianal Buschke-Lowenstein tumor with one of the widest excision in the literature without the need for diverting stoma. The tumor size and its location determined the choice of treatment option and suspected prognosis for the patient outcome. Treatment was impeded by patient's malnutrition. The giant Buschke - Loewenstein tumor was resected from the anus, perineum and gluteal areas. The large tissue losses were simultaneously covered with rotational skin and fatty subcutaneous tissue flaps, mobilized from neighboring gluteal and femoral areas. The circumferential part of the anal canal was covered with skin grafted from the mentioned flaps and it was attached to the anal mucosa. No protective stoma was formed. Despite temporary problems with healing of the covering skin flaps, full permanent coverage of the resection site has been achieved. Anal canal function has also improved within the time. CONCLUSION: The patient with BLT must be very carefully clinical and imagistic investigated in order to detect the tumor visceral invasion and to establish the extension of the surgical procedure. There exists an extensive and time-consuming surgical procedure which allows to remove the giant anorectal Buschke - Loewenstein tumors with good function of the anorectum and without the necessity of diverting stoma creation.

Iatrogenic bile duct injury. A significant surgical problem. Assessment of treatment outcomes in the department's own material.

UNLABELLED: Iatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased. The aim of the study was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014. MATERIAL AND METHODS: In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay. RESULTS: 82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%). CONCLUSIONS: The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented.

[Obstetric damage to the perineum and the anal sphincters. Reconstruction surgery]. / Poloznicze uszkodzenia krocza i aparatu zwieraczowego odbytu. Sposoby leczenia rekonstrukcyjnego.

Damage to the perineum, vulva, anal sphincters, rectal wall and the fascial structures of the pelvic floor may be caused by obstetric trauma. Emergency surgical treatment aims at control of the bleeding, anatomical reconstruction of the disrupted tissues and minimization of the risk of infection. Suturing of the rectal wall and mucosa of the anal canal is followed by reconstruction of the perineal body internal and external anal sphincters, vulva and the perineum. Delayed surgery is undertaken after the complete healing of the obstetric tear. All cicatricial fibers must be saved to reinforce sphincters and perineal body muscles suturing. Anal levators and perineal transvers muscles suturing is used for the rectovaginal septum and pelvic floor reconstruction. Anal sphincters are reconstructed by the 'overlapping' technique. X en Z suturing is used for a perineal skin plasty.

Migration of biomaterials used in gastroenterological surgery.

UNLABELLED: Mesh biomaterials have become the standard in the treatment of hernias, regardless the location. In addition to the obvious advantages of the methods based on implantable biomaterials, one should be aware of the possible complications, such as their migration to the abdominal organs. MATERIAL AND METHODS: The study group comprised patients operated at the Department of General, Gastroenterological Oncology, and Plastic Surgery during the period between 2008 and 2011, due to hernia surgery with mesh implantation. We also analysed the number of patients operated, due to complications of mesh migration during the same period. RESULTS: 368 patients were subject to mesh implantation, due to hernias during the period between 2008 and 2011. Three patients underwent surgery because of symptomatic migration of the mesh (ileus, fistula). CONCLUSIONS: The frequency of mesh migration is difficult to determine because of the different criteria of migration, observation period, and other factors. In patients after mesh implantation the potential migration of the biomaterial should be considered in case of unclear or acute abdominal symptoms.

Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis.

INTRODUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients. MATERIAL AND METHODS: Medical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study. RESULTS: All patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant. CONCLUSIONS: The IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.

Differential expression of IGF-1 mRNA isoforms in colorectal carcinoma and normal colon tissue.

The insulin-like growth factor (IGF)-1 gene consists of 6 exons resulting in the expression of 6 variant forms of mRNA (IA, IB, IC, IIA, IIB and IIC) due to an alternative splicing. The mechanisms of IGF-1 gene splicing and the role of local expression manifested by IGF-1 mRNA variants in colorectal carcinoma (CRC) have not been extensively investigated. Therefore, the aim of our study was to analyse the expression of IGF-1 mRNA isoforms [A, B, C, P1 (class I) and P2 (class II)], as well as the protein expression in CRC and control samples isolated from 28 patients. The expression of Ki-67 was also analysed and clinical data were obtained. For this purpose, we used quantitative real-time PCR (qPCR) and immunocytochemistry. The expression of mRNAs coding for all splicing isoforms of IGF-1 was observed in every tissue sample studied, with a significantly lower expression noted in the CRC as compared to the control samples. The cytoplasmic expression of IGF-1 protein was found in 50% of the CRC and in ~40% of the non-tumor tissues; however, no significant quantitative inter-group differences were observed. The expression of the IGF-1 gene in the 2 groups of tissues was controlled by the P1 and P2 promoters in a similar manner. No significant differences were detected in the expression of the IGF-1 A and B isoforms; however, their expression was significantly higher compared to that of isoform C. No significant differences were observed between the expression of Ki-67 mRNA in the CRC and control tissue even though the expression of the Ki-67 protein was higher in the CRC compared to the control samples. Ki-67 protein expression was associated with the macroscopic and microscopic aspects of CRC. A significant positive correlation was found between the local production of total mRNA and isoform A and the expression of Ki-67 mRNA, although only in the non-tumor tissues. In CRC samples, the local expression of the total IGF-1 mRNA and all splicing isoforms of IGF-1 mRNA decreased as compared to the normal colon tissues, although however, with conservation of both gene promoter activities and with the continued principal splicing IGF-1 mRNA isoforms.

[Severe complications of total pelvic floor repair using polypropylene mesh--case report]. / Ciezkie powiklania po operacji calkowitej rekonstrukcji krocza przy uzyciu siatki polipropylenowej--opis przypadku.

The authors present a case of 58 years old woman suffering from complex pelvic floor pathology diagnosed with rectal prolapse, genitary organs prolapse, descending pelvic floor, rectocele and enterocele as well as advanced diverticular disease of the left colon. She suffered from chronic constipation. The surgery consisted of left hemicolectomy, hysterectomy, reconstruction of the pelvic floor and sacrocoloporectopexy using polypropylene mesh. The out-come complicated mesenteric vessels thrombosis, small bowel perforations and intraabdominal abscesses. Despite intensive care and subsequent ileal resections, debridement and drainage of the abscesses the patient died five months after beacause of multi organs insufficiency.

Trace elements and rat pouchitis.

The procedure of restorative proctocolectomy is associated with a complete removal of the colon and slight reduction of ileum length, which together can lead to systemic shortages of trace elements. Inflammatory changes in the pouch mucosa may also have some impact. However, there is no data on trace elements in pouchitis. Therefore, in the present study we aimed to assess the effect of acute pouchitis on the status of selected trace elements in rats. Restorative proctocolectomy with the construction of intestinal J-pouch was performed in twenty-four Wistar rats. Three weeks after the surgery, pouchitis was induced. Eight untreated rats created the control group. Liver concentrations of selected micronutrients (Zn, Cu, Co, Mn, Se) were measured in both groups six weeks later, using inductively coupled plasma mass spectrometry. Liver concentrations of trace elements did not differ between the study and the control groups. However, copper, cobalt and selenium concentrations [µg/g] were statistically lower (p<0.02, p<0.05 and p<0.04, respectively) in rats with severe pouchitis (n=9) as compared with rats with mild pouchitis (n=7) [median (range): Cu--7.05 (3.02-14.57) vs 10.47 (5.16-14.97); Co--0.55 (0.37-0.96) vs 0.61 (0.52-0.86); Se--1.17 (0.69-1.54) vs 1.18 (0.29-1.91)]. In conclusion, it seems that acute pouchitis can lead to a significant deficiency of trace elements.

[Practical approach to constipation in adults]. / Praktyczne zasady postepowania w zaparciach u doroslych.

The authors present epidemiology etiology pathophysiology management, and treatment of constipation including proper qualification for surgery. Constipations can be divided into more common - primary and less frequent - secondary The latter may occur due to organic lesions of the large bowel, in the course of metabolic and endocrine disorders, or neurological and psychiatric diseases. Constipation may also be a side effect of multiple medications. In turn, primary constipation is either a slower movement of contents within the large bowel or twice as likely pelvic floor dysfunction with the inability to adequately evacuate the contents from the rectum. Symptoms such as infrequent defecation and decreased urge to defecate indicate rather colonic inertia whereas prolong straining even in case of loose stools, and feeling of incomplete evacuation are typical of obstructed defecation. Digital rectal examination reveals common anorectal defects presenting with constipation such as tumors, anal fissures and strictures, and rectocele, or less frequent changes such as rectal intussusception and enterocele. Proctologic examination should include the assessment of the anal sphincter tone and the pelvic floor movement. Barium enema or colonoscopy are necessary to confirm or exclude colorectal organic lesions, mostly in patients with alarm features. More accurate differentiation between slow transit constipation and obstructed defecation is possible with tests such as colonic transit time, defecography and anorectal manometry Treatment of constipation, irrespective of the cause, is initiated with lifestyle modification which includes exercise, increased water intake and a high-fiber diet. Pharmacologic treatment is started with osmotic agents followed by stimulant laxatives. In turn, biofeedback therapy is a method of choice for the treatment of defecation disorders. There is a small group of patients with intractable slow-transit constipation and descending perineum syndrome who require surgery Surgical treatment is also indicated in patients with symptomatic rectocele, and advanced rectal intussusception. Enterocele can be corrected during perineopexy performed for the descending perineum.

Fever of unknown origin: a clinical mask of malignant peritoneal mesothelioma.

The authors present a patient suffering from malignant peritoneal mesothelioma. Differential diagnosis has become the major concern in the fatally ill patient. Pain, increasing abdominal girth, anorexia and weight loss, and recurrent ascites are the most frequent presenting symptoms. In this patient, fever of unknown origin was a clinical mask of mesothelioma. The diagnostic process was focused on infections and collagen-vascular diseases since they are the most common causes of the systemic inflammatory response syndrome. However, persistent pyrexia can also occur, less frequently, in the course of any malignant disease.

Inulin supplementation in rat model of pouchitis.

Available data indicates potential effectiveness of prebiotic therapy in alleviating inflammation and prolonging the remission in inflammatory bowel disease. Documented successes of such therapies were the basis for this study. So far, there is no data related to the effectiveness of inulin application in symptomatic or severe pouchitis in humans or in animal model. The aim of the study was to determine the effect of inulin supplementation on the expression of intestinal inflammation and feeding efficiency in rats with induced pouchitis. Twenty-four Wistar rats were operated. After induction of pouchitis animals were randomly divided into control and supplementation groups receiving, respectively, semi-synthetic diet with or without inulin (in a lower (LD) or higher (HD) dose: 2.5 % or 5 % of total dietary content of mass) for a period of 6 weeks. Selected nutritional parameters were assessed throughout the study. Histopathological and immunohistochemical analysis of pouch mucosa specimens was also performed. The energy intake, weight gain, feeding efficiency, quality of stools were comparable in all studied groups. The intensity of inflammation (Moskovitz scale) and adaptive changes (Laumonier scale) did not differ between compared groups. The tissue expression of pro- and anti-inflammatory interleukins (IL-1α, IL-6, IL-10 and IL-12) was not different either. Inulin supplementation does not improve the quality of stools or the expression of intestinal inflammation in rats with induced pouchitis. It has no impact on the intensity of pouch adaptation or on feeding efficiency.

Abdominal rectopexy with absorbable and non-absorbable materials in the treatment for rectal prolapse.

UNLABELLED: THE AIM OF THE STUDY was to present and compare own results of abdominal rectopexy performed with absorbable and nonabsorbable materials used in surgical repair of rectal prolapse. MATERIAL AND METHODS: In the years 1991-2009, 50 patients were operated on for rectal prolapse. The first 8 patients (group I) were operated using absorbale polyglycolic acid mesh. The next 42 patients were operated using non-absorbable polypropylene mesh (group II). 12 patients with chronic, incurable constipation had sigmoidectomy and rectopexy performed at the same operation. Rectopexy was performed with the mesh and fixed to the pelvic fascia and periosteum and mesorectum, leaving the anterior one third of the rectum free. 6 months after surgery functional outcomes were evaluated. Statistic analysis with the level of statistical significance p < 0.005 was applied to obtained functional results. RESULTS: On the follow up visits, there were no symptoms of the recurrence of rectal prolapse in 5 patients (62.5%) from group I and in 25 patients (92.6%) from group II. Patients relapsing were reoperated 24 to 98 months after primary surgery. In all patients from group I (absorbable mesh), prosthetic material was not found at reoperation. In redo surgery only non-absorbable mesh was used. CONCLUSIONS: The effectiveness of rectal fixation depends on the on the durability of the prosthetic material. In the studied group polypropylene mesh was superior in rectopexy to absorbable mesh.

Vacuum-assisted closure therapy in patients with large postoperative wounds complicated by multiple fistulas.

Vacuum-assisted closure (VAC) therapy is a widely acknowledged method for chronic and traumatic wound healing. The feasibility of VAC therapy used for the treatment of intestinal fistulas is still a subject of debate. Complex postoperative wounds pose significant therapeutic problems, especially when there are several fistula openings in the wound area and other sites, usually at the site of previous drains. This paper describes the treatment of three patients in a critical condition, with complex postoperative wounds complicated by multiple fistulas. Vacuum-assisted closure therapy was based on effective drainage of the biggest fistula opening and ensuring conditions promoting the healing process of other fistulas and the wound. A considerable improvement in general condition and wound healing was noted within 2-4 weeks and both the number of fistulas and the volume of excreted contents decreased. After 5-7 weeks a significant improvement in wound healing was observed in all patients. Once the general condition of all patients was considered satisfactory (2-6 months), they underwent surgery aimed at restoration of the digestive tract continuity.In our opinion, VAC therapy used for the treatment of postoperative wounds with multiple fistulas in the wound area and other sites should aim mainly at the improvement of patients' general condition, limitation of the number of fistulas as well as accelerated wound healing. This may lead to formation of one stoma-type fistula, which can be dressed and cared for by patients until the continuity of the digestive tract has been surgically restored.