Specific Changes in Manometric Parameters are Associated with Non-improvement in Symptoms after Rectocele Repair.

INTRODUCTION AND HYPOTHESIS: The present study aimed to assess the changes in manometric parameters after transperineal repair (TPR) of rectocele and interpret failure of symptom improvement in light of these changes. METHODS: This was an observational cohort study on patients with anterior rectocele who underwent TPR in the period of February 2016 to February 2019. Data collected included patients' demographics, rectocele size, Wexner constipation and incontinence scores, anal pressures, and rectal sensation before and 12 months after TPR. Analysis of data was done by paired t-test and chi-square test. RESULTS: Forty-six female patients with a mean age of 43.2 ± 10.7 years were included. After a mean follow-up of 13.9 ± 2.7 months, 30 (65.2%) patients reported clinical improvement and 16 (34.8%) had no significant improvement. At 12 months after rectocele repair, the entire cohort studied showed an insignificant increase in the mean anal pressures and a significant decrease in the thresholds of first rectal sensation, first urge, intense urge, and maximum tolerable volume (MTV). Patients who clinically improved showed similar physiologic changes to the entire cohort examined, whereas patients who had no clinical improvement showed significant increases in the mean anal pressures and insignificant decreases in rectal sensation and MTV. CONCLUSION: Patients who showed clinical improvement showed insignificant increases in anal pressures and significant decreases in thresholds of first rectal sensation, first urge, intense urge, and MTV. Contrarily, patients who did not show clinical improvement showed significant increases in anal pressures and insignificant reduction in sensory thresholds.

Functional Outcome and Sexual-Related Quality of Life After Transperineal Versus Transvaginal Repair of Anterior Rectocele: A Randomized Clinical Trial.

BACKGROUND: Methods of treatment of rectocele include transperineal, transvaginal, and transanal approaches and ventral rectopexy. OBJECTIVE: The present randomized study aimed to compare the outcome of transperineal repair and transvaginal repair of anterior rectocele. DESIGN: This is a randomized, single-blinded clinical trial. SETTING: This study was conducted at the Colorectal Surgery Unit, Mansoura University Hospitals. PATIENTS: Adult female patients with anterior rectocele reporting obstructed defecation syndrome were selected. INTERVENTIONS: Anterior rectocele was surgically treated via a transperineal or transvaginal approach. MAIN OUTCOME MEASURES: Improvement in constipation, operation time, hospital stay, complications, changes in anal pressures, and improvement in sexual-related quality of life was assessed by use of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the incidence of dyspareunia postoperatively was assessed. RESULTS: Sixty-four female patients of a mean age of 43.5 years were entered into the trial. There was no significant difference between the 2 groups regarding the operation time. Patients undergoing transperineal repair had significantly longer hospital stays than those undergoing transvaginal repair (2.4 vs 2.1 days, p = 0.03). There was no significant difference between the 2 groups regarding postoperative complications and recurrence of rectocele. Significant decrease in the constipation scores was recorded in both groups at 6 and 12 months after surgery. The decrease in the constipation scores after transvaginal repair was significantly higher than after transperineal repair at 6 and 12 months postoperatively. Although resting and squeeze anal pressures were significantly increased at 12 months after transperineal repair, they did not show significant change after transvaginal repair. Improvement in sexual-related quality of life was significantly higher in the transvaginal repair group than in the transperineal repair group at 6 and 12 months after surgery. Dyspareunia improved after transvaginal repair and worsened after transperineal repair, yet this change was insignificant. LIMITATIONS: This was a single-center study comprising a relatively small number of patients. CONCLUSION: Transvaginal repair of rectocele achieved better improvement in constipation and sexual-related quality of life than transperineal repair. Changes in dyspareunia after both techniques were not significant. See Video Abstract at http://links.lww.com/DCR/B148. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03801291. RESULTADO FUNCIONAL Y CALIDAD DE VIDA RELACIONADA CON EL SEXO DESPUÉS DE LA REPARACIÓN TRANSPERINEAL VERSUS TRANSVAGINAL DEL RECTOCELE ANTERIOR: UN ENSAYO CLÍNICO ALEATORIZADO: Los métodos de tratamiento del rectocele incluyen los abordajes transperineal, transvaginal y transanal y la rectopexia ventral.El objetivo del presente estudio aleatorizado fue comparar el resultado de la reparación transperineal y la reparación transvaginal del rectocele anterior.Ensayo clínico aleatorizado, simple ciego.Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.Pacientes mujeres adultas con rectocele anterior que se quejan de síndrome de defecación obstruida.Tratamiento quirúrgico del rectocele anterior mediante abordaje transperineal o transvaginal.Mejora en el estreñimiento, tiempo de operación, estancia hospitalaria, complicaciones, cambios en la presión anal, mejoría en la calidad de vida relacionada con el sexo evaluada por el cuestionario PISQ-12 e incidencia de dispareunia postoperatoria.Sesenta y cuatro pacientes de sexo femenino de una edad media de 43.5 años ingresaron al ensayo. No hubo diferencias significativas entre los dos grupos con respecto al tiempo de operación. La reparación transperineal tuvo una estancia hospitalaria significativamente más prolongada que la reparación transvaginal (2.4 Vs 2.1 días, p = 0.03). No hubo diferencias significativas entre ambos grupos con respecto a las complicaciones postoperatorias y la recurrencia del rectocele. Se registró una disminución significativa en las puntuaciones de estreñimiento en ambos grupos a los 6 y 12 meses después de la cirugía. La disminución en las puntuaciones de estreñimiento después de la reparación transvaginal fue significativamente mayor que después de la reparación transperineal a los 6 y 12 meses después de la operación. Aunque las presiones anales de reposo y compresión aumentaron significativamente a los 12 meses después de la reparación transperineal, no mostraron cambios significativos después de la reparación transvaginal. La mejora en la calidad de vida relacionada con el sexo fue significativamente mayor en la reparación transvaginal que en el grupo de reparación transperineal a los 6 y 12 meses después de la cirugía. La dispareunia mejoró después de la reparación transvaginal y empeoró después de la reparación transperineal, sin embargo, este cambio fue insignificante.Estudio de un solo centro que comprende un número relativamente pequeño de pacientes.La reparación transvaginal del rectocele logró una mejoría en el estreñimiento y la calidad de vida relacionada con el sexo que la reparación transperineal. Los cambios en la dispareunia después de ambas técnicas no fueron significativos. Consulte Video Resumen en http://links.lww.com/DCR/B148.Ensayos clínicos. Identificador del gobierno: NCT03801291.

Gender-based analysis of the characteristics and outcomes of surgery for anal fistula: analysis of more than 560 cases / Análise baseada no sexo das características e desfechos de cirurgia para fístula anal: análise de mais de 560 casos

ABSTRACT Background: Fistula-in-ano commonly affects males more than females. Some differences in the characteristics of fistula-in-ano between both genders have been recognized, yet the impact of these differences on the outcomes of surgery for fistula-in-ano is still unclear. The present study conducted a gender-specific analysis aiming to assess the characteristics and the outcomes of surgery of fistula-in-ano in each gender. Patients and methods: The records of patients with fistula-in-ano were retrospectively reviewed and the following variables were extracted: patients' demographics, type of fistula-in-ano, position of the external opening, operation performed, incidence of recurrence and complications, particularly fecal incontinence. Gender-based analysis of the characters and outcomes of surgery for fistula-in-ano was performed. Results: 565 (491 males) patients of a mean age of 41.7 years were included. Females had a significantly higher percentage of low fistula-in-ano than males (70.2% vs. 50.3%, p = 0.002). Males had a significantly higher percentage of high trans-sphincteric fistula-in-ano (48.5% vs. 29.7%; p = 0.003). Anterior fistula-in-ano was more common in female patients (69% vs. 16.3%; p < 0.0001). Recurrence of fistula-in-ano was detected in 42 (7.4%) patients. Males had higher recurrence rate than females (7.9% vs. 4%; p = 0.34). Fecal incontinence developed in 1.7% of patients with higher incidence observed in females (4% vs. 1.4%). Conclusion: The majority of fistula-in-ano in males were posterior and high trans-sphincteric whereas most fistula-in-ano in females were low and anteriorly based. Despite the different characteristics of fistula-in-ano; no significant differences in the rates of fistula recurrence and fecal incontinence between males and females could be recorded.

RESUMO Background: A fístula anal comumente acomete mais os homens que as mulheres. Algumas diferenças nas características da fístula anal entre ambos os sexos têm sido reconhecidas, embora o impacto dessas diferenças nos desfechos da cirurgia para fístula anal ainda seja incerto. O presente estudo realizou uma análise específica para sexo, com o objetivo de avaliar as características e os desfechos da cirurgia de fístula anal em cada sexo. Pacientes e métodos: Os prontuários de pacientes com fístula anal foram revisados retrospectivamente e as seguintes variáveis foram extraídas: dados demográficos dos pacientes, tipo de fístula anal, posição da abertura externa, cirurgia realizada, incidência de recidiva e complicações, particularmente incontinência fecal. Realizou-se uma análise baseada no sexo dos sujeitos e desfechos da cirurgia para fístula anal. Resultados: Foram incluídos 565 pacientes (491 do sexo masculino) com idade média de 41,7 anos. As mulheres apresentaram uma porcentagem significativamente mais alta de fístula anal baixa do que os homens (70,2% vs. 50,3%, p = 0,002). Os homens tiveram uma porcentagem significativamente maior de fístula anal transesfincteriana alta (48,5% vs. 29,7%; p = 0,003). A fístula anal anterior foi mais comum em pacientes do sexo feminino (69% vs. 16,3%; p < 0,0001). A recorrência de fístula anal foi detectada em 42 (7,4%) pacientes. Os homens apresentaram maior taxa de recorrência do que as mulheres (7,9% vs. 4%; p = 0,34). A incontinência fecal desenvolveu-se em 1,7% dos pacientes com maior incidência observada no sexo feminino (4% vs. 1,4%). Conclusão: A maioria das fístulas anais no sexo masculino foi posterior e transesfincteriana alta, enquanto a maioria das fístulas anais no sexo feminino foi baixa e anterior. Apesar das diferentes características da fístula anal, não foi possível registrar diferenças significativas nas taxas de recorrência de fístula e incontinência fecal entre homens e mulheres.

Rotational gluteal flap versus modified Limberg flap in treatment of sacrococcygeal pilonidal disease.

BACKGROUND: Sacrococcygeal pilonidal disease (SPND) is a common surgical condition with a multitude of surgical treatments. The aim of this study was to compare the outcome of modified Limberg flap (MLF) and that of rotational gluteal flap (RGF) in treatment of SPND. MATERIALS AND METHODS: This was a retrospective case-controlled study involving adult patients of both genders who were treated with either MLF or RGF for SPND. The main outcomes of the study were the recurrence of SPND, complications, operation time, hospital stay, time of healing, time to return to daily activities, and cosmetic outcomes. RESULTS: A total of 189 (143 males) patients with a mean age of 23.5 y were included. Ninety-five patients were treated with RGF (cases), and 94 were treated with MLF (controls). Both the groups were matched regarding age, gender, body mass index, and disease severity. The operation time of RGF was longer than that of MLF (P < 0.0001). No significant difference in recurrence was noted between RGF and MLF (3.1% versus 7.4%, P = 0.21). RGF had lower complication rate than MLF (17.9% versus 40.4%; P = 0.001). Time to return to work was similar in both the groups. RGF conferred significantly better cosmetic outcomes than MLF. CONCLUSIONS: Both RGF and MLF achieved comparable, low recurrence rates. Although the operation time of RGF was significantly longer than that of MLF, the RGF had shorter healing time; lower complication rate, particularly seroma formation; and better cosmetic appearance.

Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh.

BACKGROUND: The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence. METHODS: The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence. RESULTS: One hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI. CONCLUSION: Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair. TRIAL REGISTRATION: Research Registry, researchregistry1891.

Does the duration of symptoms of anal fissure impact its response to conservative treatment? A prospective cohort study.

BACKGROUND: Conservative treatment is the first line of treatment for anal fissure. The current study aimed to evaluate the impact of symptom duration on the response of anal fissure to conservative treatment. PATIENTS AND METHODS: This prospective study was conducted on sixty patients with acute or chronic anal fissure who were treated conservatively with bulking agents, Sitz baths, and topical glyceryl trinitrate (GTN) 0.2%. Pain and constipation were assessed prior to treatment and at 6 weeks after therapy using visual analogue scale (VAS) and Wexner constipation score. Adverse effects as headache and postural hypotension were also queried. RESULTS: The mean pre-treatment VAS for acute fissure was significantly higher than chronic fissure (8.8 ± 0.96 Vs 5.8 ± 1.12), also the post-treatment VAS for acute fissure was significantly lower at 6 weeks of treatment (0.47 ± 0.8 Vs 2.5 ± 1.3). The baseline Wexner constipation score was comparable in both groups; however, at six weeks of treatment it declined more significantly in patients with acute fissure. Patients with acute fissure achieved significantly better healing than chronic fissure (80% Vs 40%). Healing rates decreased from 100% in patients with symptoms < one month to 33.3% in patients with symptoms >6 months. CONCLUSION: Conservative treatment including topical GTN 0.2% significantly hastened healing and relieved pain and other symptoms of acute more than chronic anal fissure. Healing rates of anal fissure in response to conservative treatment showed remarkable decrease in proportion to the duration of complaint.

Role of ursodeoxycholic acid in the prevention of gallstone formation after laparoscopic sleeve gastrectomy.

PURPOSE: Postoperative cholelithiasis (CL) is a latent complication of bariatric surgery. The aim of this study was to evaluate the role of ursodeoxycholic acid (UDCA) in the prevention of CL after laparoscopic sleeve gastrectomy (LSG). METHODS: This was a retrospective analysis of the prospectively collected data of patients with morbid obesity who underwent LSG. Patients were subdivided into two groups: Group I, which did not receive prophylactic treatment with UCDA after LSG; and Group II, which received UCDA therapy for 6 months after LSG. Patients' characteristics, operation duration, weight loss data, and incidence of CL at 6 and 12 months postoperatively were collected. RESULTS: A total of 406 patients (124 males, 282 females) with a mean age of 32.1 ± 9.4 years were included. The mean baseline body mass index (BMI) was 50.1 ± 8.3 kg/m2. Group I comprised 159 patients, and Group II comprised 247 patients. The two groups showed comparable demographics, % excess weight loss (EWL), and decrease in BMI at 6 and 12 months after LSG. Eight patients (5%) developed CL in Group I, whereas no patients in Group II did (P = 0.0005). Preoperative dyslipidemia and rapid loss of excess weight within the first 3 months after LSG were the risk factors that significantly predicted CL postoperatively. CONCLUSION: The use of UCDA effectively reduced the incidence of CL after LSG in patients with morbid obesity. Dyslipidemia and rapid EWL in the first 3 months after LSG significantly predisposed patients to postoperative CL.

Effect of age, patient's sex, and type of trauma on the correlation between size of sphincter defect and anal pressures in posttraumatic fecal incontinence.

BACKGROUND: The physiologic assessment of anal sphincters in cases of posttraumatic fecal incontinence is a fundamental step in planning operative treatment. In this study, we evaluate the correlation between size of anal sphincter defect, anal pressures, and clinical symptoms in patients with posttraumatic fecal incontinence. We also investigate the impact of patients' age, sex, and type of trauma on this correlation. METHODS: Records of 70 patients fitting the study's eligibility criteria were collected retrospectively from the archives of Mansoura University Hospitals' colorectal surgery unit. Demographic data of patients, causes of fecal incontinence, images of sphincter defects on endorectal ultrasonography, anal resting and squeeze pressures, and Wexner continence scores were collected, and correlation analysis was performed. RESULTS: Seventy patients (54 males and 16 females) with a mean (±standard deviation) age of 36 ± 16 years were studied. Mean maximal resting anal pressure was 42 ± 16 mm Hg, and mean maximal squeeze anal pressure was 80 ± 35 mm Hg. Size of external anal sphincter defect was negatively correlated with mean maximal squeeze (r = -0.4298). Mean Wexner continence score was correlated positively with size of external anal sphincter defect (r = 0.3743). Both correlations became significantly stronger in female patients, patients greater than 50 years, postfistulectomy patients, and patients with obstetric injuries. CONCLUSION: Size of external anal sphincter defect correlates negatively with mean maximal squeeze and positively with symptoms score. This correlation is stronger in females, patients greater than 50 years, and patients with postfistulectomy or obstetric injuries. These findings suggest that this group of patients requires additional assessment before surgical repair.