Clinical outcomes of surgical management for recurrent rectal prolapse: a multicenter retrospective study.

Purpose: There are few reports on outcomes following surgical repair of recurrent rectal prolapse. The purpose of this study was to examine surgical outcomes for recurrent rectal prolapse. Methods: We conducted a multicenter retrospective study of patients who underwent surgery for recurrent rectal prolapse. This study used data collected by the Korean Anorectal Physiology and Pelvic Floor Disorder Study Group. Results: A total of 166 patients who underwent surgery for recurrent rectal prolapse were registered retrospectively between 2011 and 2016 in 8 referral hospitals. Among them, 153 patients were finally enrolled, excluding 13 patients who were not followed up postoperatively. Median follow-up duration was 40 months (range, 0.2-129.3 months). Methods of surgical repair for recurrent rectal prolapse included perineal approach (n = 96) and abdominal approach (n = 57). Postoperative complications occurred in 16 patients (10.5%). There was no significant difference in complication rate between perineal and abdominal approach groups. While patients who underwent the perineal approach were older and more fragile, patients who underwent the abdominal approach had longer operation time and admission days (P < 0.05). Overall, 29 patients (19.0%) showed re-recurrence after surgery. Among variables, none affected the re-recurrence. Conclusion: For the recurrent rectal prolapse, the perineal approach is used for the old and fragile patients. The postoperative complications and re-recurrence rate between perineal and abdominal approach were not different significantly. No factor including surgical method affected re-recurrence for recurrent rectal prolapse.

Minimal Lateral Internal Sphincterotomy (LIS): Is It Enough to Cut Less Than the Conventional Tailored LIS?

PURPOSE: Anal fissure is a common anorectal condition, yet its pathogenesis remains unclear. Lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic anal fissures that do not respond to conservative treatment; however, it has a risk of anal incontinence. We believe that fibrosis of the internal anal sphincter is an important factor in the pathogenesis of chronic anal fissure. In this study, we describe the minimal LIS method, a minimally invasive method where only the fibrotic portion of the internal anal sphincter is cut. We also describe the outcomes of this method. METHODS: We performed a retrospective review of 468 patients (270 male and 198 female) who underwent minimal LIS for chronic anal fissure in 2017 at Seoul Song Do Hospital. We analyzed the patients' clinical characteristics, manometry data, complications, and outcomes of minimal LIS. The outcomes of the surgery were assessed via questionnaires during the postoperative outpatient visits, beginning 2 weeks postoperatively. RESULTS: The overall complication rate was 4.0% (19 patients). Delayed healing occurred in 14 patients (3.0%), perianal abscess was present in 3 patients (0.6%), and gas incontinence occurred in 2 patients (0.4%). All complications were improved with conservative treatment. Recurrence, defined as the recurrence of anal fissure more than 4 weeks after healing, was present in 6 patients (1.3%). CONCLUSION: Minimal LIS is a safe and effective treatment option for patients with chronic anal fissure. Postoperative complications, especially incontinence and recurrence, are rare.

Comparison of Delorme-Thiersch Operation Outcomes in Men and Women With Rectal Prolapse.

PURPOSE: The laparoscopic rectopexy has become increasingly popular with verified stability, surgical route selection should be tailored to individual patient characteristics rather than operative risk. The perineal approach is useful in young male patients who need to preserve fertility. This study aimed to compare the characteristics of men and women who underwent Delorme-Thiersch procedures and analyze the postoperative outcomes of the perineal approach by sex. METHODS: We retrospectively reviewed the medical records of 293 patients who underwent Delorme-Thiersch operations in Seoul Song Do Colorectal Hospital between January 2011 and September 2017. Patient clinical characteristics and postoperative complications were analyzed by sex. We analyzed surgical outcomes with preoperative and 3-month postoperative incontinence questionnaires, constipation levels, and anal manometry. RESULTS: In this study, men with rectal prolapse were younger than women with the same condition. American Society of Anesthesiologists physical status classifications were higher in women and women had more L-spine X-ray and pudendal nerve terminal motor latency test abnormalities. Anorectal manometry pressures were higher in men. Men also had longer operation times and hospital stays and more postoperative complications (8 T ring infections, 6 patients with bleeding, 3 with strictures, 2 with severe pain, and 2 with rectal perforations). The recurrence rate was higher among women. CONCLUSION: Men with rectal prolapse were younger, healthier, and had relatively better anorectal function than women. The Delorme-Thiersch operation in men promoted lower recurrence rates and was advantageous in preserving the fertility of young patients, but the incidence of complications was also higher in men. Adequate counseling and preparation for the possibility of complications are needed.

Laparoscopic Posterolateral Rectopexy for the Treatment of Patients With a Full Thickness Rectal Prolapse: Experience With 63 Patients and Short-term Outcomes.

PURPOSE: Although numerous procedures have been proposed for the treatment of patients with a rectal prolapse, the most effective operation has not yet been established. Minimal rectal mobilization can prevent constipation; however, it is associated with increased recurrence rates. We describe our novel method for a laparoscopic posterolateral rectopexy, which includes rectal mobilization with a posterior-right unilateral dissection, suture fixation to the sacral promontory with a polypropylene mesh (Optilene), and a mesorectal fascia propria that is as wide as possible. The present report describes our novel method and assesses the short-term outcomes of patients. METHODS: Between June 2014 and June 2017, 63 patients (28 males and 35 females) with a full-thickness rectal prolapse underwent a laparoscopic posterolateral (LPL) rectopexy. We retrospectively analyzed the clinical characteristics and postoperative complications in those patients. The outcome of surgery was determined by evaluating the answers on fecal incontinence questionnaires, the results of anal manometry preoperatively and 3 months postoperatively, the patients' satisfaction scores (0-10), and the occurrence of constipation. RESULTS: No recurrence was reported during follow-up (3.26 months), and 3 patients reported postoperative complications (wound infection, postoperative sepsis, which was successfully treated with conservative management, and retrograde ejaculation). Compared to the preoperative baseline, fecal incontinence at three months postoperatively showed an overall improvement. The mean patient satisfaction score was 9.55 ± 0.10, and 8 patients complained of persistent constipation. CONCLUSION: LPL rectopexy is a safe, effective method showing good functional outcomes by providing firm, solid fixation for patients with a full-thickness rectal prolapse.

Diagnostic value of peripheral blood immune profiling in colorectal cancer.

PURPOSE: Little is known about the clinical value of peripheral blood immune profiling. Here, we aimed to identify colorectal cancer (CRC)-related peripheral blood immune cells and develop liquid biopsy-based immune profiling models for CRC diagnosis. METHODS: Peripheral blood from 131 preoperative patients with CRC and 174 healthy controls was analyzed by flow cytometry and automated hematology. CRC-related immune factors were identified by comparing the mean values of immune cell percentages and counts. Subsequently, CRC diagnostic algorithms were constructed using binary logistic regression. RESULTS: Significant differences were observed in percentages and counts of white blood cells, lymphocytes, neutrophils, regulatory T cells, and myeloid-derived suppressor cells (MDSCs) of patients and controls. The neutrophil/lymphocyte and Th1/Th2 ratios were also significantly different. Likewise, the percentages and counts of peripheral blood programed death 1, cytotoxic T lymphocyte antigen 4, B-and T-lymphocyte attenuator, and lymphocyte activation gene-3 were higher in patients with CRC. The binary logistic regression model included 12 variables, age, CD3+%, NK%, CD4+CD279+%, CD4+CD25+%, CD4+CD152+%, CD3+CD366+%, CD3+CD272+%, CD3+CD223+%, CD158b-CD314+CD3-CD56+%, Th2%, and MDSCs cells/µL, for the prediction of cancer. Results of retrospective and prospective evaluation of the area under the curve, sensitivity, and specificity were 0.980 and 0.940, 91.53% and 85.80%, and 93.50% and 86.20%, respectively. CONCLUSION: Peripheral blood immune profiling may be valuable in evaluating the immunity of CRC patients. Our liquid biopsy-based immune diagnostic method and its algorithms may serve as a novel tool for CRC diagnosis. Future largescale studies are needed for better characterization of its diagnostic value and potential for clinical application.

Laparoscopic Vaginal Suspension and Rectopexy for Rectal Prolapse.

PURPOSE: Laparoscopic procedures for the treatment of patients with a rectal prolapse have gained increasing worldwide acceptance because they have lower recurrence and better functional outcome than perineal procedures. Nevertheless, ideal surgical methods are still not available. We propose a new surgical technique, laparoscopic vaginal suspension and rectopexy, for correcting a full-thickness rectal prolapse and/or middle-compartment prolapse. This study assessed the short-term outcomes for patients who underwent laparoscopic vaginal suspension and rectopexy. METHODS: Between April 2014 and April 2016, 69 female patients underwent laparoscopic vaginal suspension and rectopexy to correct a rectal prolapse. Demographics, medical histories, and surgical and follow-up details were collected from their medical records. In addition to the clinical outcome, we repeated defecation proctography and a questionnaire regarding functional results three months after surgery. RESULTS: No major morbidities or no mortalities occurred. The defecation proctography confirmed excellent anatomical result in all cases. Of 7 patients with combined middle-compartment prolapses, we observed good anatomical correction. During follow-up, full-thickness recurrence occurred in one patient. Preoperative fecal incontinence was improved significantly at 3 months (mean Wexner score: 12.35 vs. 7.71; mean FISI: 33.29 vs. 21.07; P < 0.001). Analysis of responses to the fecal incontinence quality of life (FIQOL) questionnaire showed overall improvement at 3 months compared to the preoperative baseline (mean pre- and postoperative FIQOL scores: 12.11 vs. 14.39; P < 0.004). CONCLUSION: Laparoscopic vaginal suspension and rectopexy is a new combined procedure for the treatment of patients with rectal prolapses. It has excellent functional outcomes and minimal morbidity and can correct and prevent middlecompartment prolapses.

The Clinical Features and Predictive Risk Factors for Reoperation in Patients With Perianal Crohn Diseases; A Multi-Center Study of a Korean Inflammatory Bowel Disease Study Group.

PURPOSE: Perianal lesions are common in Crohn disease, but their clinical course is unpredictable. Nevertheless, predicting the clinical course after surgery for perianal Crohn disease (PCD) is important because repeated operations may decrease patient's quality of life. The aim of this study was to predict the risk of reoperation in patients with PCD. METHODS: From September 1994 to February 2010, 377 patients with PCD were recruited in twelve major tertiary university-affiliated hospitals and two specialized colorectal hospitals in Korea. Data on the patient's demographics, clinical features, and surgical outcomes were analyzed. RESULTS: Among 377 patients, 227 patients were ultimately included in the study. Among the 227 patients, 64 patients underwent at least one reoperation. The median period of reoperation following the first perianal surgery was 94 months. Overall 3-year, 5-year, and 10-year cumulative rates of reoperation-free individuals were 68.8%, 61.2%, and 50.5%, respectively. In multivariate analysis (Cox-regression hazard model), reoperation was significantly correlated with an age of onset less than 20 years (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.07-3.48; P = 0.03), history of abdominal surgery (HR, 1.99; 95% CI, 1.08-3.64; P = 0.03), and the type of surgery. Among types of surgery, fistulotomy or fistulectomy was associated with a decreased incidence of reoperation in comparison with incision and drainage (HR, 0.19; 95% CI, 0.09-0.42; P < 0.001). CONCLUSION: Young age of onset and a history of abdominal surgery were associated with a high risk of reoperation for PCD, and the risk of reoperation were relatively low in fistulotomy or fistulectomy procedures.

Giant peritoneal loose body in the pelvic cavity.

We report a case of a large peritoneal loose body diagnosed on computed tomography. The most common causes of a peritoneal loose body are thought to be torsion and separation of the appendices epiploicae. Peritoneal loose bodies are usually small, 0.5 to 2.5 cm in diameter. However, "giant" peritoneal loose bodies, larger than 4 cm in diameter, are an uncommon disease and present with various symptoms, and are difficult to diagnose preoperatively. Especially, abdominal large peritoneal loose bodies are frequently misdiagnosed as tumorous disease preoperatively. In our case, the loose body appeared as a round pelvic mass with central calcifications and a distinct fat plane separating it from adjacent organs. Preoperatively, we suspected a tumorous lesion from the wall of the upper rectum; however, at laparoscopy, a large peritoneal loose body was detected. An extraction of the giant peritoneal loose body was performed laparoscopically.

Rectal prolapse: review according to the personal experience.

The aim of treatment of rectal prolapse is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. Faced with a multitude of options, the choice of an optimal treatment is difficult. It is best tailored to patient and surgeon. Numerous procedures have been described and are generally categorized into perineal or abdominal approaches. In general, an abdominal procedure has associated with lower recurrence and better functional outcome than perineal procedures. The widespread success of laparoscopic surgery has led to the development of laparoscopic procedures in the treatment of complete rectal prolapse. In Korea, there has been a trend toward offering perineal procedures because of the high incidence of rectal prolapse in young males and its being a lesser procedure. Delorme-Thiersch procedure has appeal as a lesser procedure for patients of any age or risk category, especially for elderly low-risk patients, patients with constipation or evacuation difficulties, young males, and patients with symptomatic hemorrhoids or mucosal prolapse. Laparoscopic suture rectopexy is recommended for either low-risk female patients or patients who are concerned with postoperative aggravation of their incontinence.

Clinical Study and Review of Articles (Korean) about Retrorectal Developmental Cysts in Adults.

PURPOSE: A retrorectal developmental cyst (tailgut cyst, epidermoid cyst, dermoid cyst, teratoma, and duplication) is very rare disease, and the symptoms are not characteristic so that sometimes this disease is still misdiagnosed as a supralevator abscess or a complex anal fistula. We would like to present a clinical approach to this disease. METHODS: We retrospectively examined the charts of 15 patients who were treated for retrorectal cysts from January 2001 to November 2009. RESULTS: All 15 patients were female. The average age was 41 years (range, 21 to 60 years). Fourteen patients (93.3%) were symptomatic, and the most common symptom was anal pain or discomfort. Nine patients (60%) had more than one previous operation (range, 1 to 9 times) for a supralevator abscess, an anal fistula, etc. In 12 patients (80%), the diagnosis could be made by using the medical history and physical examination. Thirteen cysts (80%) were excised completely through the posterior approach. The average diameter of the cysts was 4.8 cm (range, 2 to 10 cm). Pathologic diagnoses were 8 tailgut cysts (53.3%), 5 epidermoid cysts (33.3%) and 2 dermoid cysts (13.3%). The average follow-up period was 18.3 months (range, 1 to 64 months). CONCLUSION: In our experience, high suspicion and physical examination are the most important diagnostic methods. If a female patient has a history of multiple perianal operations, a retrorectal bulging soft mass, a posterior anal dimple, and no conventional creamy foul odorous pus in drainage, the possibility of a retrorectal developmental cyst must be considered.

Familial occurrence of inflammatory bowel disease in Korea.

BACKGROUND: Little information is available about the familial aggregation of inflammatory bowel disease (IBD) in Asian populations. We therefore determined the risk of familial aggregation of IBD among first-degree relatives of patients with ulcerative colitis (UC) or Crohn's disease (CD) in an ethnically distinct Korean population. METHODS: Familial aggregation of IBD was evaluated in terms of family history, prevalence, lifetime risk, and population relative risk in first-degree relatives of 1440 unrelated patients with UC (n = 1043) or CD (n = 397). RESULTS: A positive first-degree family history of IBD was observed in 27 probands (1.88%): 21 of 1043 (2.01%) with UC and 6 of 397 (1.51%) with CD. The crude prevalence of IBD in first-degree relatives of probands with IBD was 0.31%. The lifetime risk of IBD was 0.54% in all first-degree relatives of IBD probands, 0.52% in UC probands, and 0.67% in CD probands, with overall lifetime relative risks of 0.12% in parents, 0.79% in siblings, and 1.43% in offspring. The age- and sex-adjusted population relative risk of IBD was 13.8 in first-degree relatives of probands with IBD. CONCLUSIONS: Although a positive family history, prevalence, and lifetime risk of IBD among first-degree relatives of Korean IBD patients are much lower than among relatives of Western patients, the population relative risk in first-degree relatives is about equal in Koreans and Westerners. This finding indicates that a positive family history is an important risk factor for IBD in Koreans and in Westerners.

Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome.

BACKGROUND AND AIMS: Two theories have been reported for the pathophysiology of levator ani syndrome: the spastic cycle hypothesis and the local inflammation (Tendinitis) hypothesis. This study compared two treatment modalities in order to determine which of the two hypotheses is more appropriate. SUBJECTS AND METHODS: In this prospective study, Group EGS (n=22) underwent electrogalvanic stimulation twice a week. Group LI (n=31) underwent a local injection of a 40-mg triamcinolone acetonide mix with 1 ml 2% lidocaine into the maximal tender point of the arcus tendon in the levator ani muscle. RESULTS: The most common location of tenderness was the left anterior of the arcus tendon of the levator ani muscle. At the last follow-up (12 months), the LI group showed more relief, more improvement, and fewer failures than the EGS group. No difference was seen between the mean pain scores (verbal analog scale: 0-100) of the two groups at either the 1-week or the 12-month follow-up. However, the LI group showed better results at the 1-month, 3-month, and 6-month follow-ups. CONCLUSION: The LI group showed better short-term results than the EGS group. Therefore, the tendinitis hypothesis seems to be the more reliable one for levator ani syndrome. However, because the subjective responses of the patients indicated that a sufficient level of patient satisfaction had not been achieved, we cannot positively conclude that the tendinitis hypothesis is the more reliable one for the pathophysiology of levator ani syndrome.

Effect of 0.2 percent glyceryl trinitrate ointment on wound healing after a hemorrhoidectomy: results of a randomized, prospective, double-blind, placebo-controlled trial.

PURPOSE: Glyceryl trinitrate ointment acts as a dilator of the internal anal sphincter. It has been used as a treatment modality that replaces the lateral sphincterotomy in chronic anal fissures. When glyceryl trinitrate ointment is applied to the wound from a hemorrhoidectomy, it is thought that it will shorten the healing time and decrease postoperative pain. Our study focused on the efficacy of using 0.2 percent glyceryl trinitrate ointment to shorten the healing time after a hemorrhoidectomy. METHODS: A randomized, prospective, double-blind, and placebo-controlled study was designed. The power test indicated that 55 patients should be in each group to give a 90 percent chance of finding a 30 percent difference in healing time. The selection criteria for inclusion in this study were patients with third-degree or fourth-degree hemorrhoids and patients undergoing hemorrhoidectomies for three or more piles. From November 2000 to July 2001, the first 110 patients to meet our criteria were selected, 55 in the nitroglycerin group and 55 in the placebo group. The same physician performed all of the hemorrhoidectomies, and intravenous patient-controlled analgesia was not used. Cases involving other procedures for fissures or fistulas were excluded. The patients randomly received glyceryl trinitrate and placebo ointments from the pharmacologist. The pain score was checked using a visual analog scale (minimum = 0, maximum = 10) during the hospital stay, and complete wound healing was checked at three weeks after the operation. Demands for analgesics and the frequency of postoperative complications were recorded. RESULTS: When the trial was completed, 49 patients remained in the nitroglycerin group and 53 patients in the placebo group. No significant differences in the gender and the age distributions, the number of excised piles, the time for the procedures, the length of hospital stay, and the consumed amounts of analgesics existed between the two groups. The pain score in the nitroglycerin group showed a significant difference with the repeated measures analysis (P < 0.001). The wound healing rates at three weeks postoperative were 74.5 percent in the nitroglycerin group and 42 percent in the placebo group (P = 0.002). There was no significant increase in complications in the nitroglycerin group. CONCLUSION: More rapid healing of hemorrhoidectomy wounds without any specific complications was effected by 0.2 percent glyceryl trinitrate ointment.