[Wound Healing Disorders after Excision and Open Treatment for Pilonidal Sinus]. / Wundheilungsstörungen nach Exzision und offener Behandlung eines Sinus pilonidalis.

INTRODUCTION: Pilonidalis sinus disease is a mostly chronic selective infection of the hairy skin in the area of skin wrinkles, mainly in the area of the natal cleft. Open treatment is still the most common recommended therapy. Nevertheless, there may be healing disorders within the framework of open wound treatment, which can significantly complicate the course. METHODS: The following is an overview of wound healing disorders after excision of pilonidalis sinus. Healing time and frequency are determined on the basis of current data and the causes of the healing disorder are evaluated. In addition, possible treatment options are presented and treatment recommendations are made. RESULTS: The evaluation of published data on wound healing period showed that the wound usually heals after a mean of two months. The results of the German forces cohort study show by way of example that almost all wounds have healed in the period up to three months. However, a small percentage of non-healing wounds remain. The frequency of significantly delayed wound healing is given in the literature as 2 - 5%. The influencing factors for wound healing after sinus pilonidalis excision are not only the size and symmetry of the excision wound but also other details of open wound treatment. In addition to intensification of the previous open wound treatment, the new excision and refreshment of the wound are mentioned as treatment options in the event of a lack of wound healing. Furthermore, changes in strategy for plastic-reconstructive procedures or other surface treatment are also recommended. CONCLUSION: The excision wound of pilonidalis sinus should be healed after three to four months at the latest, after which the wound can be regarded as a wound with significantly delayed healing or as a wound healing disorder. Around this time, the findings should be re-evaluated and, if necessary, a change in the treatment concept should be made.

Long-Term Results After Stapled Hemorrhoidopexy: A 15-Year Follow-Up.

BACKGROUND: The stapled hemorrhoidopexy is reported to have a low recurrence while treating the major hemorrhoidal symptoms of bleeding and prolapse. The aim of this study is to obtain long-term results on the outcome of the stapled hemorrhoidopexy. METHODS: All patients with a hemorrhoidal disease grade III, who underwent stapled hemorrhoidopexy from May 1999-December 2003, were included. Data collection was based on a standardized telephone interview. In the questionnaire, we recorded information regarding the postoperative recurrence and severity of hemorrhoidal symptoms (defined as bleeding, prolapse, burning, itching and moisture), further hemorrhoidal treatments and functional results (incontinence, fecal urgency and outlet obstruction) as well as patients' satisfaction. RESULTS: Of the 257 patients, who underwent stapled hemorrhoidopexy, follow-up data were available in 140 patients. In 47.4% of the patients, a recurrence of at least one hemorrhoidal symptom was registered, whereas this recurrence was observed in 47.3% of these patients more than 10 years postoperatively. A surgical re-intervention was necessary in 15.2%. We found a postoperative new incontinence in 15.5%, a fecal urgency in 28.0% and an outlet obstruction in 9.4%. Of all patients, 62.3% were "very satisfied" with the operation. CONCLUSIONS: The results of the study revealed a relatively high recurrence of hemorrhoidal symptoms after a mean follow-up of 15 years with a high recurrence rate more than 10 years postoperatively. In consideration of not negligible risk of incontinence, fecal urgency and outlet obstruction, the indication for a stapled hemorrhoidopexy should be made well considered. However, patients' satisfaction is very high.

German S3 guidelines: anal abscess and fistula (second revised version).

BACKGROUND: The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men. METHODS: This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature. RESULTS: Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate. CONCLUSION: In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

German S3 guideline: anal abscess.

BACKGROUND: The incidence of anal abscess is relatively high, and the condition is most common in young men. METHODS: A systematic review of the literature was undertaken. RESULTS: This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. CONCLUSION: In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.

Rethinking the causes of pilonidal sinus disease: a matched cohort study.

Our understanding of pilonidal sinus disease (PSD) is based on a paper published 29 years ago by Karydakis. Since then, surgeons have been taught that hair more easily penetrates wet skin, leading to the assumption that sweating promotes PSD. This postulate, however, has never been proven. Thus we used pilocarpine iontophoresis to assess sweating in the glabella sacralis. 100 patients treated for PSD and 100 controls were matched for sex, age and body mass index (BMI). Pilocarpine iontophoresis was performed for 5 min, followed by 15 min of sweat collection. PSD patients sweated less than their matched pairs (18.4 ± 1.6 µl vs. 24.2 ± 2.1 µl, p = 0.03). Men sweated more than women (22.2 ± 1.2 µl vs. 15.0 ± 1.0 µl in non-PSD patients (p < 0.0001) and 20.0 ± 1.9 µl vs. 11.9 ± 2.0 µl in PSD patients (p = 0.051)). And regular exercisers sweated more than non-exercisers (29.1 ± 2.9 µl vs. 18.5 ± 1.6 µl, p = 0.0006 for men and 20.7 ± 2.3 µl vs. 11.4 ± 1.4 µl, p = 0.0005 for women). PSD patients sweat less than matched controls. Thus sweating may have a protective effect in PSD rather than being a risk factor.

Long-term results of stapled transanal rectal resection (STARR) for obstructive defecation syndrome.

BACKGROUND: Rectocele and distal rectal intussusception are organic causes of obstructive defecation syndrome and can be corrected surgically once conservative treatment remedies have been exhausted. Stapled transanal rectal resection (STARR) procedure was introduced as a new treatment approach. This study presents the first long-term results of this procedure. PATIENTS AND PROCEDURES: A STARR procedure was performed in 14 patients (two male, 12 female, age 53 ± 12 years) between January 2003 and August 2005. The indication for surgery was a severe, conservatively treated stool evacuation disorder secondary to symptomatic rectocele and/or distal intussusception. RESULTS: The mean follow-up period was 68 ± 10 (49-83) months. The defecation score (0-20 points) decreased from a preoperative 13.4 ± 3.4 to 3.2 ± 2.0 after 3 months and increased slightly to 4.7 ± 3.4 by the time of the final examination. In 12 patients (85.7%), the obstructive defecation syndrome was significantly improved. These positive results were also maintained in the long-term. Five patients (38.5%) reported a slight worsening of continence in terms of urge incontinence. The most affected patients were those with preoperative normal continence. Procedure-related anal reoperations were required in two patients (14.3%). CONCLUSION: Even in long-term, transanal rectal wall resection seems to be an effective therapy for obstructive defecation syndrome. However, it is associated with a substantial number of reoperations and in some patients with persistent urge incontinence.

The Management of Pilonidal Sinus.

BACKGROUND: Pilonidal disease is an acute or chronic infection in the subcutaneous fatty tissue, mainly in the natal cleft. Its incidence in Germany in 2012 was 48 cases per 100 000 persons per year. METHODS: This review is based on pertinent publications retrieved by a selective literature search. RESULTS: The numerous minimally invasive techniques that are available for the treatment of pilonidal disease have the advantages of being relatively atraumatic and of enabling the patient to continue working almost without interruption. They are suitable for small lesions that have not been previously surgically treated. These techniques are associated with a higher recurrence rate than excisional methods (level of evidence [LoE]: Ib). It is not yet clear whether minimally invasive techniques employing laser or endoscopic technology can reduce the recurrence rate. In systematic meta-analyses, the duration of wound healing was shorter after off-midline techniques (the Karydakis procedure, the Limberg procedure, and others) than after excision with open wound treatment; the off-midline techniques should, therefore, be preferred for patients who have undergone previous surgery and for those with large lesions (LoE: Ia). Excision with midline suturing should not be performed (LoE: Ia). Postoperative permanent shaving cannot be recommended either (LoE: IV). CONCLUSION: Further randomized trials are needed to clarify the role of newer techniques in the treatment of pilonidal disease.

Posterior retroperitoneoscopic adrenalectomy--results of 560 procedures in 520 patients.

BACKGROUND: The posterior retroperitoneoscopic adrenalectomy is less popular than the laparoscopic transabdominal method. Due to the direct approach to the adrenal glands, however, the posterior retroperitoneal access is easy to use and may offer advantages not available with other endoscopic procedures for adrenalectomy. METHODS: Between July 1994 and March 2006, we performed 560 adrenalectomies (right side: n = 258; left side: n = 302) by the posterior retroperitoneoscopic approach in 520 patients (200 male, 320 female; age, 10 to 83 years). Of the 520 patients, 21 suffered from Cushing's disease, 499 patients had adrenal tumors (157 Conn's adenomas, 120 pheochromocytomas [13 bilateral], 110 Cushing's adenomas [6 bilateral], and 112 other tumors). Tumor size ranged from 0.5 to 10 cm (mean, 2.9 +/- 1.7 cm). The procedures were performed with the patients in the prone position usually with 3 trocars. RESULTS: Mortality was zero. Conversions to open or laparoscopic lateral surgery were necessary in 9 patients (1.7%). Major complications occurred in 1.3% of patients, minor complications in 14.4%. Mean operating time was 67 +/- 40 min and declined significantly (P < .001) from the early procedures (106 +/- 46 min) to the later operations (40 +/- 15 min). CONCLUSIONS: The posterior retroperitoneoscopic adrenalectomy is a safe and fast procedure. In experienced hands, this method represents the ideal approach in adrenal surgery.

TST36 stapling for rectocele and hemorrhoidal prolapse - early results of the prospective German multicenter study.

Introduction: The aim of the study was to evaluate the safety and feasibility of stapled transanal procedures performed by a 36 mm stapling device, the so-called TST36 stapler. Methods: From September 2013 to June 2014 a prospective observational study was carried out by 8 proctology centers in Germany. The Cleveland Clinic Incontinence Score (CCIS) for incontinence and the Altomare ODS score were determined preoperatively. Follow-up examinations were performed after 14 days, one month and 6 months, at this time both scores were reevaluated. Results: 110 consecutive patients (71 women, 39 men) with a mean age of 59.7 years (±13.8 years) were included in the study. The eight participating institutes entered 3 to 31 patients each into the study. The indication for surgery was an advanced hemorrhoidal disease in 55 patients and ODS with rectal intussusception or rectocele in 55 patients. Mechanical problems with stapler introduction occurred in 22 cases (20%) and a partial stapleline dehiscence in 4 cases (3.6%). Additional stitches for bleeding from stapleline were necessary in 86 patients (78.2%). Reintervention was necessary for bleeding 7 times (6.3%). Severe complications during follow-up were stapleline dehiscence in one case and recurrent hemorrhoidal prolapse in 5 cases (4.5%). Altomare ODS score and CCIS improved significantly after surgery. Conclusions: Despite a notable complication rate during surgery and the postoperative period, the TST36 can be considered as an effective tool for low rectal stapling for anorectal prolapse causing hemorrhoids or obstructed defecation.

[Management of complications of fissure and fistula surgery]. / Komplikationsmanagement in der Fissur- und Fistelchirurgie.

BACKGROUND: Fistula-in-ano and anal fissures are common proctological diseases. In most cases of anal fissures conservative treatment provides good clinical results, whereas for fistula-in-ano operative treatment is the only option. OBJECTIVE: The most important and for the patient most stressful long-term complication is postoperative incontinence, especially as the deliberate severance of the anal sphincter musculature is part of the treatment for many patients. In this article the causes and treatment options are discussed. RESULTS: The therapy of choice for patients with persisting symptoms caused by an anal fissure is fissurectomy. Incontinence disorders develop due to severance of parts of the internal sphincter or resection of the anoderm. In patients with anal fistulas the occurrence of incontinence disorders depends on the anatomical relationship of the fistula to the sphincter, the surgical procedure and also on pre-existing damage, e.g. from childbirth or other sphincter trauma and scar formation, notably in patients with multiple surgical interventions. Severance of the sphincter muscles in proximal transsphincteric and suprasphincteric fistulas in particular bears a high risk of postoperative incontinence. Data from the literature regarding postoperative fecal incontinence vary enormously due to different follow-up intervals and also variable definitions of the term fecal incontinence. CONCLUSION: Options for the treatment of postoperative fecal incontinence are limited. Treatment of postoperative incontinence should first be conservative. Surgical repair of damaged sphincter muscles is often of limited success and sacral nerve stimulation might be an option in selected patients. Especially in patients with fissure-in-ano the indications for surgery should be strictly adhered to. For fistula-in-ano the least invasive and most sphincter-preserving procedure should be selected.

German S3-Guideline: rectovaginal fistula.

BACKGROUND: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. METHODS: A systematic review of the literature was undertaken. RESULTS: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. CONCLUSION: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.

Cryptoglandular anal fistulas.

BACKGROUND: Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life. METHOD: This S3 guideline is based on a systematic review of the pertinent literature. RESULTS: The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate. CONCLUSION: This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.