[Laparoscopic approach in the pelvic floor surgery]. / Technika laparoskopického prístupu v pánevní chirurgii.

Laparoscopy offers great exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing and bowel manipulation making it an excellent modality to perform pelvic floor surgery. Laparoscopic repair of level I or apical vaginal prolapse may be challenging, due to the need for extensive dissection and advanced suturing skills. However it offers the efficacy of open abdominal sacrocolpopexy, such as lower recurrence rates and less dyspareunia than sacrospinous fixation, as well as the reduced morbidity of a laparoscopic approach.

Long-term outcome of endoscopic dilatation in patients with Crohn's disease is not affected by disease activity or medical therapy.

BACKGROUND: Endoscopic dilatation of Crohn's disease-related strictures is an alternative to surgical resection in selected patients. The influence of disease activity and concomitant medical therapy on long-term outcomes is largely unknown. AIM AND METHODS: To study the long-term safety and efficacy of stricture dilatation in a single centre cohort. RESULTS: Between 1995 and 2006, 237 dilatations where performed in 138 patients (mean age 50.6+/-13.4, 56% female) for a clinically obstructive stricture (<5 cm, 84% anastomotic). Immediate success of a first dilatation was 97% with a 5% serious complication rate. After a median follow-up of 5.8 years (IQR 3.0-8.4), recurrent obstructive symptoms led to a new dilatation in 46% or surgery in 24%. Niether elevated levels of C-reactive protein nor endoscopic disease activity predicted the need for new intervention. None of the concomitant therapies influenced the outcome. CONCLUSION: This largest series ever reported confirms that long term efficacy of endoscopic dilatation of Crohn's disease outweighs the complication risk. Neither active disease at the time of dilatation nor medical therapy afterwards predict recurrent dilatation or surgery.

Belgian consensus guideline on the management of hemorrhoidal disease.

Introduction: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Outcome of surgery for rectovaginal fistula due to Crohn's disease.

BACKGROUND: This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing. METHODS: Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment. RESULTS: Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients. CONCLUSION: Fistula closure was achieved in most patients, but more than one operation was often required.

Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett's neoplasia.

BACKGROUND: Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett's neoplasia. Adequate staging is important to assure a good oncological outcome. OBJECTIVE: The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett's oesophagus (BE) and the cardia. METHODS: Between November 2005-May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen. RESULTS: The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%). CONCLUSION: The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett's dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barrett's dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.

Small doses of the unabsorbable substance polyethylene glycol 3350 accelerate oro-caecal transit, but slow gastric emptying in healthy subjects.

BACKGROUND: Polyethylene glycol 3350 increases stool frequency and accelerates colonic transit. Used as a laxative, it proved effective in patients with normal and slow transit. Although free of severe side effects, it may cause nausea and vomiting. The effect of this substance on upper gut transit has not been studied. AIM: To investigate the effect of polyethylene glycol 3350 on gastric emptying and oro-caecal transit in 12 healthy subjects. METHODS: In a randomised controlled study, isosmotic polyethylene glycol 3350 electrolyte balanced solution, in the maximal recommended dose or isosmotic electrolyte solution, was administered after breakfast and lunch on separate days. Gastric half-emptying time and oro-caecal transit time were measured using [13C]-octanoate and lactose-[13C] ureide breath tests. RESULTS: Isosmotic polyethylene glycol 3350 electrolyte solution, as compared to isosmotic electrolyte solution, decreased oro-caecal transit time from 424+/-28 to 314+/-17 min (P = 0.001). Gastric half-emptying time was significantly increased (84+/-6 min versus 127+/-14 min; P = 0.006). CONCLUSION: Polyethylene glycol 3350 accelerate oro-caecal transit in healthy subjects, but also cause an important delay in gastric emptying. The delay in gastric emptying may be of clinical significance in patients who have associated gastroparesis.

A risk-benefit assessment of cisapride in the treatment of gastrointestinal disorders.

Cisapride is a substituted benzamide compound that stimulates motor activity in all segments of the gastrointestinal tract by enhancing the release of acetylcholine from the enteric nervous system. Cisapride is administered orally in the treatment of gastro-oesophageal reflux disease, functional dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction syndromes and chronic constipation. In gastro-oesophageal reflux disease in both adults and children, cisapride provides symptomatic improvement and mucosal healing. Long term treatment with cisapride is effective in the prevention of relapse of oesophagitis. Cisapride improves gastric emptying rates and improves symptoms in patients with gastroparesis of various origins. Unlike domperidone and metoclopramide, long term administration of cisapride seems to result in persistently enhanced gastric emptying. Cisapride is also effective in improving symptoms in patients with functional dyspepsia. In comparative studies in patients with functional dyspepsia, cisapride was at least as effective as metoclopramide, domperidone, clebopride, ranitidine and cimetidine. Cisapride increases stool frequency and reduces laxative consumption in patients with idiopathic constipation. Severe cases of slow transit constipation seem refractory to cisapride. Clinical studies also indicate that cisapride might be effective in the treatment of chronic intestinal pseudo-obstruction, postoperative ileus, peptic ulcer and irritable bowel syndrome. Further clinical studies are warranted to define the role of cisapride in these conditions. The dosage of cisapride ranges from 5mg 3 times daily to 20mg twice daily. Cisapride is generally well tolerated, both during short and long term treatment. In children, cisapride is also well tolerated in doses of 0.2 to 0.3 mg/kg, 3 to 4 times daily.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of continuous isobaric rectal distension on gastric emptying and small bowel transit in young healthy women.

Patients with slow transit constipation frequently have delayed gastric emptying. In animals rectal distensions inhibit gastrointestinal motility. In healthy volunteers isovolumetric rectal distensions delay upper gut transit. The purpose of this study was to determine the effect of continuous isobaric rectal distension on gastric emptying and oro-cecal transit in young females. Using validated 13C octanoic and lactose-[13C] ureide breath tests gastric half-emptying time and oro-cecal transit time for a meal were measured in 12 volunteers. The tests were repeated in randomized order: during isobaric balloon distension and during sham distension. Isobaric rectal distension was applied using a polyethylene bag connected to a barostat. Intraballoon pressure was kept just below the threshold for the urge sensation. Mean gastric half-emptying time during rectal distension (92.3 +/-5.1 min) was significantly higher than during sham distension (78.8 +/- 4 min; P = 0.015). Mean oro-cecal transit time during rectal distension (391.3 +/-29.1 min) and sham distension (328.8 +/- 38.4 min) were not significantly different. In conclusion, these findings indicate that isobaric rectal distension inhibits gastric emptying, but not small bowel transit in young healthy women. Studies in patients with constipation are indicated.

Surgical aspects of severe chronic non-Hirschsprung constipation.

This paper reviews the methods available for selecting patients with disabling non-Hirschsprung constipation eligible for surgery, and the surgical methods reported. It is concluded that careful evaluation of the patient may help in selecting the most suitable treatment. The demonstration, however, of a specific morphological abnormality would, of itself, not seem to justify surgical correction. The surgical criteria remain to be defined by additional physiological research, and the outcome of the various surgical procedures is always uncertain. Surgery should only be undertaken in patients with disabling symptoms, in whom prolonged conservative treatment has failed completely.

Computer-supported analysis of continuous ambulatory manometric recordings in the human small bowel.

An algorithm has been developed for the offline analysis of prolonged manometric recordings in the upper small intestine of humans. Sample data are acquired in the human duodenum and jejunum six solid-state strain-gauge transducers mounted on a silicon catheter that is connected to a portable digital recording device. The data are sampled at 4 Hz and filtered. For accurate calculations, the filtered signals are converted to cubic B-spline functions of order four. Based on an exponential weighted moving average, a base-line is calculated from the signal. Contractions are recognised on the basis of thresholds for minimum amplitude and duration. The developed algorithm calculates properties of these contractions, such as amplitude, duration, area and a motility index. In addition, the program automatically recognises normal motor patterns of the fasted human small intestine, such as the migrating motor complex, and aids in the identification of the postprandial motor pattern. Motor patterns are defined in terms of properties such as contraction frequency and propagation. In a validation procedure using conventional manual analysis, the program correctly identifies the number of individual contractions with a 98% confidence interval and also correctly recognises 96% of phase 3 motor activity.

Efficacy and safety of rioprostil, 300 micrograms b.d., in the treatment of duodenal ulcer: a double-blind, controlled multicentre clinical study vs. ranitidine.

This study is undertaken to evaluate the efficacy and safety of rioprostil, 300 micrograms, compared with ranitidine, 150 mg, when given twice daily for 4-6 weeks to patients with active, uncomplicated duodenal ulcer. The effects of each drug on ulcer healing are evaluated by endoscopy. Of a total of 355 patients who have entered this study, 319 are statistically evaluated for efficacy; 162 receive rioprostil and 157 receive ranitidine. After 4 weeks of treatment, 63% of the patients receiving rioprostil are endoscopically healed, compared with 72% of those receiving ranitidine. After 6 weeks of treatment, the cumulative healing rates are 86% and 93.5% respectively; this difference is statistically significant. Diarrhoea is the main adverse event, but is generally mild and self-limiting. These results indicate that rioprostil, 300 micrograms b.d., is a safe and effective treatment for duodenal ulcer, but is slightly less effective than ranitidine, 150 mg b.d.

Laparoscopic sacrocolpopexy.

Laparoscopy offers great exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing-- and bowel manipulation making it an excellent modality to perform pelvic floor surgery. Laparoscopic repair of level I or apical vaginal prolapse may be challenging, due to the need for extensive dissection and advanced suturing skills. However, it offers the efficacy of open abdominal sacrocolpopexy, such as lower recurrence rates and less dyspareunia-- than sacrospinous fixation, as well as the reduced morbidity of a laparoscopic approach.

An evidence-based treatment algorithm for anal fissure.

Guidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings.

Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature.

Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.

Do anal fistulas in Crohn's disease behave differently and defy Goodsall's rule more frequently than fistulas that are cryptoglandular in origin?

OBJECTIVES: The complexity of anal fistulas is different in patients with and without Crohn's disease and in men and women. This may affect the localization of the internal orifice. We compared the characteristics of anal fistulas and the accuracy of Goodsall's rule in predicting the position of the internal orifice in male and female Crohn's and non-Crohn's patients. METHODS: A total of 191 fistula tracks in 182 consecutive patients (110 men and 72 women) were analyzed prospectively. Of the patients, 63 were diagnosed with Crohn's disease. The positions of the orifices were recorded and the accuracy of Goodsall's rule determined. RESULTS: The distribution of fistula subtypes among Crohn's and non-Crohn's patients differed significantly (p = 0.0471). Fistulas with an anterior external opening occurred more frequently in Crohn's patients (p = 0.0350) and in women (p = 0.0030). Fistulas with a posterior external orifice were observed more frequently in non-Crohn's patients (p = 0.0350) and in men (p = 0.0028). Overall, Goodsall's rule performed less well in women compared with men (p = 0.0633). The accuracy of Goodsall's rule overall was not affected by Crohn's disease. In female non-Crohn's patients, the positive predictive value of a posterior external orifice was lower than in men (p = 0.0406). CONCLUSIONS: The distribution of fistula subtypes and the ratio of anterior and posterior external openings among Crohn's and non-Crohn's patients differ significantly. Many fistulas defy Goodsall's rule, particularly in women and when applied to fistulas with anterior external orifices. The popular rule, however, falls equally short in Crohn's and non-Crohn's fistulas.

Gastrointestinal motility disorders.

A classification of gastrointestinal motility disorders is offered based upon the type of disorder in transit (delay or acceleration), and the region of the gastrointestinal tract affected. Specific abnormalities of myoelectrical patterns are identified when possible and related to disturbances in transit in the stomach and small bowel.

Does intercurrent hepatitis have a beneficial effect on the course of Crohn's disease?

Four patients who developed acute viral hepatitis in the course of active Crohn's disease are reported upon. Three of these patients (1 with hepatitis A and 2 with hepatitis B) had a very striking and unusual clinical remission or apparent healing on regression of the hepatitis. These observations suggest that intercurrent hepatitis may have a beneficial effect on the course of active Crohn's disease.

Achalasia, diffuse esophageal spasm, and related motility disorders.

From 1972 to 1977, the authors observed 156 patients with primary esophageal motility disorders which caused such a severe degree of dysphagia that treatment by pneumatic dilatation was deemed necessary. Before dilatation, 24% of the patients presented with motility disorders that did not fit well into the two classical disease entities, diffuse esophageal spasm and achalasia (absence of peristalsis with presence of lower esophageal sphincter (LES) relaxations or presence of peristalsis with absence of LES relaxations). After treatment with pneumatic dilatation, these "intermediate" forms constituted 45% of the motor disorders. This was due mainly to the reappearance, on manometric tracings, of peristaltic contractions and of LES relaxations. Radiologic and manometric observations suggest that in many patients, this "return of peristalsis" may be an apparent change in pressure pattern rather than a real change in motility. In 6 of the 156 patients, a deterioration of the esophageal motility disorder was observed, which was characterized by the loss of peristalsis and of LES relaxations over a period of a few months or years. The frequent occurrence of intermediate types of motility disorders and the transition from diffuse spasm to achalasia suggest that achalasia and diffuse esophageal spasm are part of a spectrum of related motor disorders.