Hybrid seton for the treatment of high anal fistulas: results of 128 consecutive patients.

BACKGROUND: The aim of this study was to evaluate our experience in managing high anal fistulas with a simple modification of the cutting seton. METHODS: We performed a retrospective review of standardized patient charts and of prospectively collected scores and questionnaires. Surgical outcomes of 128 consecutive, well-documented patients with high anal fistulas, including anterior transsphincteric fistulas in females, treated using a hybrid seton, were analyzed. RESULTS: No significant complications occurred. The mean postoperative pain scores on a visual analog scale were 3.23 and 0.61, on days 1 and 7, respectively. Complete healing was achieved in 67 cases (52.3 %) at 1 month and in all cases (100 %) at 3 months. Recurrent fistula was noted in 2 patients (1.5 %) at 6 and 12 months. The mean postoperative incontinence scores at 3 and 12 months did not differ significantly from the preoperative score (p = 0.061, Wilcoxon's test). The depression, life style, and embarrassment item scores of the fecal incontinence quality of life index improved significantly after surgical treatment. CONCLUSIONS: The results of this series suggest that the hybrid seton might be a valid alternative for the treatment of high anal fistulas, eliminating the need for postoperative adjustments. The slow and stable cutting of the sphincter seems to have a positive effect on the maintenance of continence. The successful outcome is associated with significant improvement in quality of life.

Treatment for horseshoe fistula with the modified Hanley procedure using a hybrid seton: results of 21 cases.

BACKGROUND: The aim of the present study was to document our recent experience in managing horseshoe fistula of cryptoglandular origin with a modification of the Hanley procedure using a hybrid elastic one-stage cutting seton. METHODS: Surgical outcomes of the modified Hanley procedure for horseshoe fistulae using a seton from 2004 through 2010 were analyzed. The seton fashioned from a surgical glove was tied around the sphincter under less tension than a traditional cutting seton, hence the definition of "hybrid seton". In addition to excision of the superficial segments of the lateral tracts, deeper extensions into the ischiorectal spaces were curetted, and Penrose drains were placed. RESULTS: All of the patients were discharged on the first postoperative day. None required readmission or needed narcotic analgesics after discharge. Complete healing was achieved in all 21 cases at 8.0 ± 3.22 weeks postoperatively. Patients were able to return to regular work activity in 3.5 ± 1 weeks. The postoperative Cleveland Clinic Incontinence Score did not differ significantly from the preoperative score (p = 0.317, Wilcoxon's test). Recurrent fistula was noted in a single patient (4.8 %) after a mean follow-up of 20.9-months. CONCLUSIONS: The use of the hybrid elastic seton is a useful and safe additional modification for the treatment of horseshoe fistulae with the Hanley technique.

Intestinal perforation due to phytobezoar obstruction: a case report.

Phytobezoars are uncommon causes of acute abdomen. We report a patient who presented with acute abdomen and who was intra-operatively diagnosed as having a small intestinal perforation due to an intestinal phytobezoar.

Retrorectal hemangiopericytoma: a case report.

Hemangiopericytoma is a rare, vascular soft tissue tumour originating from the pericytes, the contractile cells that surround capillaries. A case of retrorectal hemangiopericytoma in a 49-year-old woman is reported. With a posterior sagittal approach, the tumour was completely removed. Pathological examination, including immunohistological stains, was consistent with a hemangiopericytoma. A step-by-step approach to a retrorectal tumour is exemplified, and a very rare pathological entity is added to the spectrum of retrorectal masses.

L-alanin-L-glutamine supplementation improves the outcome after colorectal surgery for cancer.

OBJECTIVE: To investigate the effect of l-alanine-l-glutamine (Gln) on postoperative complication rate and duration of hospitalization in patients operated for colorectal cancer. METHOD: A total of 109 patients operated with the diagnosis of colorectal cancer and given enteral nutrition between January 2001 and January 2005 were prospectively analysed. The patients were randomized and analysed in two groups; Gln group (n = 57): patients were given parenteral Gln (1 g/kg/day, Dipeptiven, Fresenuis Kabi, Germany) together with enteral nutrition (Ensure; Abbott, Zwolle, The Netherlands) and the control group (n = 52) only received enteral nutrition (Ensure; Abbott), which was a standard isonitrogenous and isocaloric formula. The supplemental enteral nutrition was provided for at least 5 days pre- and postoperatively according to the nutritional status of the patients. Age, gender, subjective global assessment (SGA), body mass index (BMI), serum albumin, protein, associated disorders, localization of pathology, techniques of anastomosis, postoperative complications and length of hospital stay were analysed for each patient. RESULTS: The duration of nutritional support in the Gln group was 6 +/- 2 and 5 +/- 1 days pre- and postoperatively; while it was 7 +/- 1 and 6 +/- 1 days for the control group, and there were no significant difference among the groups (P > 0.05). Age, gender, SGA, BMI, levels of serum albumin and protein, localization of pathology and techniques of anastomosis were also similar (P > 0.05). Wound infection (P = 0.038), intraabdominal abcess formation (P = 0.044) and wound dehiscence (P = 0.044) were significantly higher in the control group than in the Gln group. There was no significant difference in terms of anastomotic leakage and other complications between both groups (P > 0.05). Hospital stay was significantly shorter in the Gln group (P < 0.001). CONCLUSION: Supplementation of parenteral Gln decreased the postoperative complications and hospital stay and in the patients undergoing the colorectal surgery for cancer.

Posterior tibial nerve stimulation for faecal incontinence after partial spinal injury: preliminary report.

BACKGROUND: This study evaluated the possible effects of posterior tibial nerve stimulation in two patients with faecal incontinence due to partial spinal cord injury. METHODS: Posterior tibial nerve stimulation was performed for 30 min, every other day for 4 weeks, and was then repeated every 2 months for three months. Clinical examination, anorectal physiological work-up, faecal incontinence severity index, and quality of life assessments were performed before and after the treatment. RESULTS: After posterior tibial nerve stimulation, patients showed improvement in rectal sensory threshold, pudendal nerve terminal motor latency, Wexner faecal incontinence score, faecal incontinence severity index, faecal incontinence quality of life scales, resting pressure, and maximum squeeze pressure measurements. CONCLUSIONS: Posterior tibial nerve stimulation can be an effective method for the treatment of faecal incontinence caused by partial spinal cord injury.

Vascular endothelial growth factor, c-erbB-2 and c-erbB-3 expression in colorectal adenoma and adenocarcinoma.

AIM: To analyze vascular endothelial growth factor (VEGF), c-erbB-2 and c-erbB-3 expression and to evaluate their relation to clinicopathologic parameters and pathogenesis of colorectal carcinoma. METHODS: Sections of adenoma, intramucosal carcinoma and adenocarcinoma were evaluated by immunohistochemistry in 85 malignant and 37 benign colorectal neoplasms for the expression of VEGF, c-erbB-2 and c-erbB-3 considering clinicopathological variables. RESULTS: VEGF was detected in comparable percentages of all neoplasm types while c-erbB-2 expression was detectable more frequently in adenoma than adenocarcinoma cases (65% vs 43%). Except for the correlation of c-erbB-3 expression with Dukes' staging, there was no correlation between the studied markers and grade of differentiation, Dukes' stage and localization of colorectal adenocarcinoma. c-erbB-3 expression was seen more frequently in tubular adenomas, while c-erbB-2 expression was higher in tubulovillous and villous types. These differences were not statistically significant. The presence of distant metastasis and angiolymphatic invasion were identified as independent predictors of survival. A positive correlation was found between VEGF expression and lymphatic vessel invasion and regional lymph node involvement. CONCLUSION: These results suggest that VEGF, c-erbB-2, c-erbB-3 expression does not have prognostic value in colorectal cancer. VEGF expression may be implicated in the lymph node metastasis.

Colonic metastasis from squamous carcinoma of the lung: report of a case and review of the literature.

We describe a rare case with metastatic involvement of the gastrointestinal tract (colonic metastasis) secondary to lung cancer. After diagnostic work-up, a left hemicolectomy was performed. Patient has been alive and healthy 9 months after operation. We report the first case with the longest survival period after the diagnosis of metastasis, although the symptomatic gastrointestinal metastases from lung cancer generally follow a poor prognosis because of their advanced state and multiplicity.

Colorectal intervention as part of surgery for patients with gynaecological malignancy.

OBJECTIVE: This study was conducted to determine the indications for and outcome of colorectal intervention in patients with advanced gynaecological malignancy. METHODS: Between January 1999 and June 2004, 27 gynaecological cancer patients underwent 36 colorectal intervention performed by general surgeons. The 36 operations were associated with 14 (39%) primary surgical procedures, 9 (25%) second-look laparotomies, and 13 (36%) procedures for recurrence or palliation. RESULTS: The mean age was 56 years (range 32-83 years). The majority of operations were performed in patients with ovarian (67%), endometrial (18%) and cervical (15%) malignancy. The primary indications for colorectal resection was tumour cytoreduction in 56% of the 36 operations. Other indications included repair of iatrogenic bowel injuries (n = 9, 25%), resection for multiple iatrogenic enterotomies (n = 4, 11%), and bowel obstruction (n = 3, 8%). The most frequently performed bowel operation was rectosigmoid resection with end-to-end anastomosis (n = 19, 53%). Colostomy was performed in 14% of the rectosigmoid resections at primary surgery. Small-bowel resection was required in 31% of the 36 operations. Postoperative complications included wound complications (14%), pulmonary infections (8%), cardiac complications (6%) and intra-abdominal abscess (6%). There was a single surgical mortality (3%). CONCLUSION: Colorectal intervention is frequently indicated during operations for advanced gynaecological malignancy, and they are associated with a significant rate of postoperative complications. Specialists operating on gynaecological malignancy should have the technical skills necessary to perform these procedures.

Intradermal methylene blue injection for the treatment of intractable idiopathic pruritus ani: results of 30 cases.

Some cases of idiopathic pruritus anu may be refractory to treatment with dietary and hygienic instructions and short-term topical medications. In this study, we documented our technique and results with methylene blue injection in a large series of patients with intractable idiopathic pruritus ani. The results of 30 adult patients with well-documented intractable idiopathic pruritus ani who were treated with intradermal methylene blue injection are reported. No antibiotic prophylaxis, anesthesia or sedation was used. A total of 15 ml of a 1% methylene blue solution was injected intracutaneously and subcutaneously in the affected perianal area. A second injection (rescue treatment) was offered one month later to patients who declared partial response, and follow-up was restarted. One month after injection, 24 patients (80%) were symptom-free, 5 declared partial remissions, and one patient still had the same degree of pruritus ani. Five patients with partial remission underwent a second methylene blue injection, which provided complete relief in four. Therefore, the early response rate was 80% with single injection and 93.3% (28 of 30) with the rescue treatment. At six months, three recurrences were noted, indicating to a success rate of 83.3% (25 of 30). At 12 months after treatment, 23 patients (76.7%) were symptom free. This study has shown that intradermal methylene blue injection is a safe, simple, fast and efficient method of treating intractable idiopathic pruritus ani.

Modified Limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery.

BACKGROUND: The present study analyses the results of wide excision with primary closure (PC), wide excision with classical Limberg flap reconstruction (LF) and wide excision with modified Limberg flap reconstruction (MLF) in the surgical treatment of sacrococcygeal pilonidal disease. METHODS: One hundred and sixty-two well-documented patients who were operated on for pilonidal disease and followed for more than 1 year were analysed retrospectively. Group 1 was composed of patients with excision plus PC (n = 78) while group 2 included those with excision plus a LF reconstruction (n = 40), and group 3 included those with excision plus a MLF reconstruction (n = 44). RESULTS: There were no significant differences among the three groups with respect to age, sex distribution, frequency of recurrent disease, or follow-up periods (P > 0.05 for all comparisons). Significant disadvantages regarding postoperative infection rate, mobilization time, discharge from hospital, and time off work were noted for primary closure, compared with both LF and MLF reconstructions. Following a median follow-up period of 4.2 years, 14 recurrences (17.9%) developed in the PC group, three (7.5%) in the LF group, and none (0%) in the MLF group. The zero recurrence rate in the MLF group was significantly lower than that in the PC group (P = 0.003). On the other hand, the recurrence rate in the LF was not found to differ significantly from that in the PC group (P = 0.126). Comparing the LF and MLF groups, none of the surgical end points reached a statistically significant difference (P > 0.05 for all comparisons). CONCLUSIONS: For the surgical treatment of sacrococcygeal pilonidal disease, excision plus a classical or modified Limberg flap reconstruction proved to be superior to excision plus primary closure in terms of infection, mobilization time, discharge from hospital and time off work. Additionally, MLF reconstruction resulted in a statistically lower recurrence rate when compared with PC.

Elastic one-stage cutting seton for the treatment of high anal fistulas: preliminary results.

BACKGROUND: The management of high and complicated anal fistulas remains a therapeutic challenge, and the oldest and theoretically the simplest technique is to use a seton. In this article, we document our recent experience in managing high anal fistulas with a simple modification of the cutting seton. PATIENTS AND METHODS: Surgical outcomes of patients treated by the elastic cutting seton for anal fistulas that involved more than half of the sphincter muscles or for anterior trans-sphincteric fistulas in female patients were analyzed. The elastic seton, which was created by cutting a thin (2-3 mm) circular strip from a surgical glove, including its thicker sleeve, was inserted through the remaining tract in a double-strand fashion, and then tied on the sphincter with two knots in a slightly tight manner. RESULTS: Complete healing was achieved in 9 cases (45%) at 1 month and in all cases (100%) at 3 months postoperatively. Recurrent fistula was noted in a single patient (5%) at 8 months. Worsening of preoperative continence was noted in 4 patients (20%). However, the postoperative incontinence score (0.70+/-1.22) did not differ significantly from the preoperative score (0.41+/-0.41; p=0.059, Wilcoxon's test). CONCLUSIONS: The preliminary results of this series suggest that the elastic cutting seton may be a valid alternative for the treatment of high anal fistulas. The possible positive contribution of the slow and stable cutting of the sphincter on the maintenance of continence is further supported. An important practical disadvantage of the conventional seton treatment, namely the need for postoperative adjustments, is also eliminated.

Neoadjuvant radiotherapy in anorectal malignant melanoma.

Primary anorectal malignant melanoma is a rare neoplasm that carries a poor prognosis with a high metastatic potential. A case of a 60-year-old male who was admitted to the emergency service with signs of colonic obstruction forced us to reconsider diagnostic and therapeutic implications in anorectal melanoma. Following urgent decompression with laparoscopic sigmoid loop colostomy, the patient was treated with preoperative radiotherapy and local excision. He has since been free of disease for 30 months. The previously published reports are reviewed and the current therapeutic options are discussed.

Effects of carbon dioxide pneumoperitoneum on free radical formation in lung and liver tissues.

BACKGROUND: The purpose of this study was to investigate the possible effects of carbon dioxide (CO2) pneumoperitoneum on free radical formation and lipid peroxidation in the lung and liver tissues of rats. METHODS: For this study, 50 male Sprague-Dawley rats were divided into five equal groups: control (group 1); sham operation (group 2); 5, 10, or 15 mmHg (group 3, 4, or 5) pneumoperitoneum with CO2 groups. At the end of the procedures, the rats were killed, and perfusion was performed via vena jugularis with cold Ringer's lactate. After the perfusion procedure, the lung and liver were harvested, and the supernatant fractions of the lungs and livers were assayed for superoxide dismutase (SOD), catalase (CAT), and malondialdehyde (MDA). RESULTS: Both the lung and liver CAT activities were elevated consistently and significantly in the order of the study groups, as compared with the previous groups (p < 0.01 for all comparisons). The lung and liver SOD levels were elevated in groups 4 and 5, as compared with the other groups (p < 0.05). The lung MDA was significantly higher in groups 3 and 4, but not in group 5. Significant elevation in liver MDA was noted only in the 5-mmHg pnemoperitoneum group (p < 0.05). CONCLUSIONS: These results indicate that CO2 pneumoperitoneum applied with 5, 10, or 15 mmHg pressure increases the formation of free oxygen radicals, which is counterbalanced by increased SOD and CAT activities of the lung and liver tissues. This effect of CO2 pneumoperitoneum on free radicals and lipid peroxidation appears to be pressure dependent in rats. The mechanism underlying this pressure dependency is still under investigation.

Gastrointestinal quality of life in patients with symptomatic or asymptomatic cholelithiasis before and after laparoscopic cholecystectomy.

BACKGROUND: There is an ongoing need, from both the medical and the economic perspective, for a more accurate definition of the influence of symptomatic or asymptomatic gallstone disease on gastrointestinal symptomatology, as well as on the health of the individual in general. METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), 37 symptomatic and 30 asymptomatic gallstone patients were evaluated at admission to the hospital and again 4 months after undergoing an uneventful laparoscopic cholecystectomy (LC). RESULTS: Postoperatively, significant increases in the total GIQLI score were noted in both the symptomatic group (113.42 +/- 21.9 vs 80.32 +/- 19.1 preoperatively; p < 0.05) and the asymptomatic group (96.37 +/- 14.26 vs 113.30 +/- 15.22; p < 0.05). For the subgroups of items, the core symptoms and the physical, psychological, and disease-specific items improved significantly in both groups in the postoperative period (p < 0.05 for all comparisons), but only the symptomatic group achieved a significant improvement in the subgroup of social items (p < 0.05). Negative correlations were found in both the symptomatic and asymptomatic groups between the preoperative GIQLI scores and the improvement seen after LC (r = -0.70 and r = -0.49, respectively). CONCLUSION: Gallstone disease has a profoundly negative impact on quality of life, especially in symptomatic patients with a history of biliary colic attacks and/or the complications of the disease. Although the condition is not equally distressing for the asymptomatic group of patients without such a history, uncomplicated LC improves the quality of life significantly in both groups. Gallstone patients with lower GIQLI scores are more likely to benefit from LC.

Efficacy of calcium dobesilate in treating acute attacks of hemorrhoidal disease.

PURPOSE: A randomized, double-blind, controlled study was conducted to investigate the efficacy of oral calcium dobesilate therapy in treating acute attacks of internal hemorrhoids. METHODS: Twenty-nine well-documented adult patients with first- or second-degree internal hemorrhoids were treated with calcium dobesilate for two weeks, while16 patients received only a high-fiber diet to serve as control. Both symptoms and anoscopic inflammation were scored on a scale from 0 to 2 before (T0) and two weeks after treatment (T2). RESULTS: A success rate of 86.21 percent with cessation of bleeding plus lack of severe anitis anoscopically at two weeks were achieved with calcium dobesilate. The pretreatment symptom score of 2 fell significantly to 0.45 +/- 0.13, and the pretreatment anitis score of 1.69 +/- 0.09 fell to 0.55 +/- 0.12 at T2 (P = 0.0001 for both comparisons). The symptom and anoscopic inflammation scores obtained with calcium dobesilate treatment were also significantly better than those with diet only (P = 0.0017 and P = 0.0013, respectively). CONCLUSION: Together with recommendations about diet and bowel discipline, oral calcium dobesilate treatment provides an efficient, fast, and safe symptomatic relief from acute symptoms of hemorrhoidal disease. This symptomatic healing is associated with a significant improvement in the anoscopically observed inflammation.

Fournier's gangrene after hemorrhoidectomy: association with drug-induced agranulocytosis. Report of a case.

An unusual case of Fournier's gangrene after hemorrhoidectomy and drug-induced agranulocytosis, as the predisposing condition, is described. The patient had severe granulocytopenia that was attributed to the recent use of dipyrone. Together with hemodynamic resuscitation, broad-spectrum antibiotic and recombinant human granulocyte colony-stimulating factor were started. Wide surgical excision of all the gangrenous tissues, in addition to laparoscopic formation of a defunctioning sigmoid loop colostomy, was performed. The white blood cell count rose steadily and the patient experienced a rapid recovery. We emphasize that radical surgery must be accompanied by pharmacologic interventions for a successful outcome in such cases.