Transcutaneous Tibial Nerve Stimulation as Therapy for Functional Constipation.

BACKGROUND: Functional constipation is a common disorder that is difficult to treat on occasion. Symptoms of this condition can per- sist despite dietary modification, exercise, and medication. Results of neuromodulation with nerve stimulation have been promising in terms of efficiency for treatment-resistant patients. This study aimed to investigate the efficacy of bilateral transcutaneous tibial nerve stimulation as a noninvasive treatment method for functional constipation. METHODS: We evaluated 105 patients with functional constipation diagnosed using the Rome IV criteria. Bilateral transcutaneous elec- trical nerve stimulation was utilized for transcutaneous tibial nerve stimulation for 6 weeks; 3 sessions were conducted every week, with each session lasting for at least 30 minutes. The Constipation Severity Instrument was used before treatment, at the end of 6 weeks, and at 12 weeks (6 weeks after the end of treatment). The effects of transcutaneous tibial nerve stimulation on the time spent in the toilet and the use of softeners were investigated. RESULTS: Of the 105 patients included in the study, 41 (39%) were male. The mean age was 43.1 (range, 19-64 years). Transcutaneous tibial nerve stimulation was found to reduce the time patients spent in the toilet. The use of softeners decreased from 76.2% to 20% (P < .001). Obstructive defecation (P < .001), colonic inertia (P < .001), pain (P < .001), and Constipation Severity Instrument total score (P < .001) improved after the 6-week treatment period. The treatment effect persisted until the 12th week. CONCLUSION: Bilateral transcutaneous tibial nerve stimulation is a noninvasive, easily applicable, and effective treatment for functional constipation, without major adverse effects. Large randomized controlled trials are required so that transcutaneous tibial nerve stimula- tion can be established as an alternative treatment for functional constipation that is resistant to standard care and laxative agents.

Comparative evaluation of efficiency for gastroileostomy anastomosis in laparoscopic transit bipartition with sleeve gastrectomy between linear and circular staplers.

INTRODUCTION: The use of Transit Bipartition with Sleeve Gastrectomy (SG + TB) to treat obesity and type 2 diabetes related to it has been increasing, but there are many challenges related to the procedure. The anastomosis diameter of gastroileostomy (GI) performed using linear staplers is an important factor affecting the postoperative metabolic status. AIM: We aimed to compare linear-stapled (LS) and circular-stapled (CS) GI in SG + TB in terms of early and late perioperative and postoperative status. MATERIAL AND METHODS: This retrospective study included 24 patients who had undergone SG + TB between January 2018 and June 2019 to treat obesity and/or type 2 diabetes. GI was performed using linear staplers in 13 (SG + TB-LS group) and circular staplers in 11 patients (SG + TB-CS group). Operative time, hospitalization duration, complications, body mass index, haemoglobin A1c, albumin, haemoglobin, etc. were compared between the 2 groups before and 12 months after the surgery. RESULTS: The operation time was shorter in the SG + TB-CS group than in the SG + TB-LS group. The surgical treatments were successful in both groups in terms of weight loss and diabetes remission. Although not statistically significant, malnutrition and anaemia were slightly higher in the SG+TB-LS group than in the SG + TB-CS group during the follow-up process. CONCLUSIONS: Both anastomosis types were found to be safe for SG+TB, and the risks of postoperative complications were low and comparable in both groups. However, the diameter of the anastomosis should always be the gold standard in the CS technique, while it may be too wide or too narrow in the LS technique.

The importance of laboratory tests and Body Mass Index in the diagnosis of acute appendicitis.

<b>Background:</b> Acute appendicitis is the most common cause of acute abdomen. Delay in diagnosis increases the mortality and morbidity. <br><b>Aim: </b>In this study, we aimed to investigate whether the body mass index is useful in diagnosis and whether the neutrophil /lymphocyte and platelet/lymphocyte ratios can help in determining the inflammation level of acute appendicitis. <br><b>Meterial and Methods:</b> Cases of appendectomy performed between June 2012 and December 2018 in our clinic were analyzed retrospectively. Based on the pathology results of the cases included in the study, 4 groups were formed, i.e.: Group 1 (initial stage), Group 2 (catarrhal stage), Group 3 (phlegmonous-gangrenous stage) and Group 4 (perforation). The study compared age, body mass index, leukocyte values, red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR), platelet /lymphocyte ratio (PLR), and mean platelet volume (MPV) between groups. <br><b> Results:</b> 828 cases were included in the study. When compared between groups, the values of Group 3 and Group 4 were higher than those of Group 1 and Group 2 for PLR and NLR. There was no difference in RDW and MPV values in the blood. When Body Mass Index (BMI) was compared between groups, it was found to be significantly higher with increasing histopathological stage. <br><b>Conclusion:</b> In acute appendicitis, the blood leukocyte value, elevated PLR and NLR are helpful in diagnosis. We aimed to emphasize that the diagnosis of acute appendicitis is delayed in patients with a BMI above 30 and/or at age of over 40 years, with the perforation rate being determined more frequently.

Can the risk of anal fistula development after perianal abscess drainage be reduced?

OBJECTIVE: Perianal abscesses are frequently seen in clinical practice, and perianal fistulas develop in 30%-50% of cases after treatment. This study investigated whether the type of dressing applied after abscess drainage is correlated with fistula development. Prevention of fistula formation would reduce both the loss of work and healthcare costs. METHODS: The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed. Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1. Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2. The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared. RESULTS: Between-group differences in age, sex, body mass index, and type of fistula that developed after months and 1 year of the abscess drainage were not statistically significant (p > 0.05). During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001). The risk of perianal fistula development was significantly increased in those with a body mass index (BMI) > 30 (p = 0.004). CONCLUSIONS: After perianal abscess drainage, in-hospital washing and dressing of the abscess area until abscess closure reduced the risk of perianal fistula, lost work time, and cost. The risk of perianal fistula development appeared to increase with BMI. A large, prospective study is needed for confirmation.

The effect of nitric oxide, endothelial nitric oxide synthetase, and asymmetric dimethylarginine in hemorrhoidal disease.

AIM: The aim of this study was to examine the roles of nitric oxide (NOx), endothelial nitric oxide synthetase (eNOS), and asymmetric dimethylarginine (ADMA), which is the major endogenous inhibitor of nitric oxide synthases (NOS), in the pathophysiology of hemorrhoidal disease. METHODS: This study included 54 patients with grades 3 and 4 internal hemorrhoidal disease and 54 patients without the disease who attended the General Surgery Clinic. NOx, eNOS, and ADMA levels were measured with the Enzyme-Linked ImmunoSorbent Assay (ELISA) method. RESULTS: The patients had higher NO and eNOS levels and lower ADMA levels than the control subjects (p<0.001). A significant highly positive correlation was found between NO and eNOS (p<0.001). Nevertheless, there was a highly negative correlation between ADMA and NO-eNOS(p<0.001, p<0.001). CONCLUSION: This preliminary study reveals that higher NOx and eNOS activities and lower ADMA levels in the rectal mucosa are observed in patients with hemorrhoidal disease than in those with normal rectal tissue. The imbalance between endothelium-derived relaxing factors, such as NO and endogenous competitive inhibitor of NOS, ADMA, may cause hemorrhoidal disease. Our study proposes that hemorrhoids display apparent vascular dilatation and present with bleeding or swelling. ADMA is an effective NOS inhibitor and may be a promising therapeutic option for hemorrhoidal disease.

The effect of nitric oxide, endothelial nitric oxide synthetase, and asymmetric dimethylarginine in hemorrhoidal disease

SUMMARY AIM The aim of this study was to examine the roles of nitric oxide (NOx), endothelial nitric oxide synthetase (eNOS), and asymmetric dimethylarginine (ADMA), which is the major endogenous inhibitor of nitric oxide synthases (NOS), in the pathophysiology of hemorrhoidal disease. METHODS This study included 54 patients with grades 3 and 4 internal hemorrhoidal disease and 54 patients without the disease who attended the General Surgery Clinic. NOx, eNOS, and ADMA levels were measured with the Enzyme-Linked ImmunoSorbent Assay (ELISA) method. RESULTS The patients had higher NO and eNOS levels and lower ADMA levels than the control subjects (p<0.001). A significant highly positive correlation was found between NO and eNOS (p<0.001). Nevertheless, there was a highly negative correlation between ADMA and NO-eNOS(p<0.001, p<0.001). CONCLUSION This preliminary study reveals that higher NOx and eNOS activities and lower ADMA levels in the rectal mucosa are observed in patients with hemorrhoidal disease than in those with normal rectal tissue. The imbalance between endothelium-derived relaxing factors, such as NO and endogenous competitive inhibitor of NOS, ADMA, may cause hemorrhoidal disease. Our study proposes that hemorrhoids display apparent vascular dilatation and present with bleeding or swelling. ADMA is an effective NOS inhibitor and may be a promising therapeutic option for hemorrhoidal disease.

RESUMO OBJETIVO O objetivo deste estudo foi examinar os papéis do óxido nítrico (NOx), do óxido nítrico sintetase endotelial (eNOS) e da dimetilarginina assimétrica (ADMA), que é o principal inibidor endógeno das óxido nítrico sintase (NOS) na fisiopatologia da doença hemorróida. MÉTODOS Este estudo incluiu 54 pacientes com doença hemorróida interna de grau 3 e 4 e 54 pacientes sem a doença que se inscreveram na Clínica Geral de Cirurgia. Os níveis de NOx, eNOS e ADMA foram medidos com o método de Ensaio Imuno absorvente ligado a enzima (ELISA). RESULTADOS Os pacientes têm níveis mais altos de NO e eNOS e níveis mais baixos de ADMA do que os indivíduos controle (p <0,001). Uma correlação altamente positiva significativa foi encontrada entre o NO-eNOS (p <0,001). No entanto, houve uma correlação negativa muito séria entre ADMA e NO-eNOS (p <0,001, p <0,001). CONCLUSÃO Este estudo preliminar revela que os pacientes com doença hemorróida têm atividades mais altas de NOx e eNOS e níveis mais baixos de ADMA na mucosa retal do que os pacientes com tecido retal normal. Desequilíbrio entre o fator relaxante derivado do endotélio, como; O NO e o inibidor competitivo endógeno da NOS, ADMA, podem causar doenças hemorróidas. Nosso estudo propõe que as hemorróidas exibam aparente dilatação vascular e apresentam sangramento ou inchaço, a ADMA é um inibidor eficaz da NOS e pode ser uma opção terapêutica promissora para a doença hemorróida.

Can the risk of anal fistula development after perianal abscess drainage be reduced?

SUMMARY OBJECTIVE Perianal abscesses are frequently seen in clinical practice, and perianal fistulas develop in 30%-50% of cases after treatment. This study investigated whether the type of dressing applied after abscess drainage is correlated with fistula development. Prevention of fistula formation would reduce both the loss of work and healthcare costs. METHODS The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed. Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1. Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2. The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared. RESULTS Between-group differences in age, sex, body mass index, and type of fistula that developed after months and 1 year of the abscess drainage were not statistically significant (p > 0.05). During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001). The risk of perianal fistula development was significantly increased in those with a body mass index (BMI) > 30 (p = 0.004). CONCLUSIONS After perianal abscess drainage, in-hospital washing and dressing of the abscess area until abscess closure reduced the risk of perianal fistula, lost work time, and cost. The risk of perianal fistula development appeared to increase with BMI. A large, prospective study is needed for confirmation.

RESUMO OBJETIVO Abscessos perianais são vistos com freqüência na clínica e uma fístula perianal se desenvolve em 30% a 50% dos casos após o tratamento. Este estudo investigou se o tipo de curativo aplicado após a drenagem do abscesso está correlacionado com o desenvolvimento da fístula. A prevenção da formação de fístulas reduziria a perda de trabalho e os custos com saúde. MÉTODOS Os prontuários de pacientes com drenagem de abscessos perianais entre janeiro de 2015 e janeiro de 2018 foram revisados retrospectivamente. Os pacientes com curativos pós-operatórios trocados com a lavagem da área no hospital foram incluídos no grupo 1. Os pacientes com curativos trocados em casa e a área banhada em 10% de banho de povidona com iodo povidona-Sitz foram incluídos no grupo 2. A frequência e o tempo de fístula formação, idade, sexo, custo e dias de trabalho perdidos nos dois grupos foram comparados. RESULTADOS As diferenças entre os grupos em idade, sexo, índice de massa corporal e o tipo de fístula que se desenvolveu após 3 meses e 1 ano após a drenagem do abscesso não foram estatisticamente significantes (p> 0,05). Durante o acompanhamento, o desenvolvimento da fístula foi significativamente menor no grupo 1 do que no grupo 2 (p <0,001). O risco de desenvolvimento de fístula perianal aumentou significativamente naqueles com índice de massa corporal (IMC)> 30 (p = 0,004). CONCLUSÕES Após a drenagem do abscesso perianal, a lavagem hospitalar e o curativo da área do abscesso até o fechamento do abscesso reduziram o risco de fístula perianal, perda de tempo de trabalho e custo. O risco de desenvolvimento de fístula perianal pareceu aumentar com o IMC. Um grande estudo prospectivo é necessário para confirmação.

The importance of laboratory tests and Body Mass Index in the diagnosis of acute appendicitis.

<b>Background:</b> Acute appendicitis is the most common cause of acute abdomen. Delay in diagnosis increases the mortality and morbidity. <br><b>Aim: </b>In this study, we aimed to investigate whether the body mass index is useful in diagnosis and whether the neutrophil /lymphocyte and platelet/lymphocyte ratios can help in determining the inflammation level of acute appendicitis. <br><b>Meterial and Methods:</b> Cases of appendectomy performed between June 2012 and December 2018 in our clinic were analyzed retrospectively. Based on the pathology results of the cases included in the study, 4 groups were formed, i.e.: Group 1 (initial stage), Group 2 (catarrhal stage), Group 3 (phlegmonous-gangrenous stage) and Group 4 (perforation). The study compared age, body mass index, leukocyte values, red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR), platelet /lymphocyte ratio (PLR), and mean platelet volume (MPV) between groups. <br><b> Results:</b> 828 cases were included in the study. When compared between groups, the values of Group 3 and Group 4 were higher than those of Group 1 and Group 2 for PLR and NLR. There was no difference in RDW and MPV values in the blood. When Body Mass Index (BMI) was compared between groups, it was found to be significantly higher with increasing histopathological stage. <br><b>Conclusion:</b> In acute appendicitis, the blood leukocyte value, elevated PLR and NLR are helpful in diagnosis. We aimed to emphasize that the diagnosis of acute appendicitis is delayed in patients with a BMI above 30 and/or at age of over 40 years, with the perforation rate being determined more frequently.

Effects of bilateral transcutaneous tibial nerve stimulation on constipation severity in geriatric patients: A prospective clinical study.

AIM: Constipation is the most common digestive complaint in the general population, and one of the most frequently encountered health problems in the geriatric population. In the present study, we aimed to determine whether bilateral transcutaneous tibial nerve stimulation affects constipation severity in geriatric patients with refractory chronic constipation. METHODS: Bilateral transcutaneous tibial nerve stimulation was carried out three times per week for 30 min in geriatric patients aged >65 years with less than three defecations per week. The patients were evaluated, and constipation severity was compared before the treatment, at the end of the 6-week treatment and 12 weeks after the end of the treatment. RESULTS: Assessment carried out using the Constipation Severity Instrument showed that the scores for subscales; that is, obstructive defecation, colonic inertia and pain, improved significantly by the end of the treatment compared with the scores obtained before the treatment. Furthermore, the improvement in pain continued for 12 weeks after the treatment, and although there was a slight decrease in the scores for the other subscales, they significantly improved compared with the scores obtained before the treatment. CONCLUSIONS: During the 12-week follow-up period, bilateral transcutaneous tibial nerve stimulation significantly improved constipation severity in geriatric patients with refractory chronic constipation. We believe that this easy-to-use and low-cost method can be applied to eligible geriatric patients who cannot be treated through dietary adjustments and/or medical interventions. Geriatr Gerontol Int 2020; 20: 101-105.

Gastrointestinal stromal tumor leading to acute abdomen and hypovolemic shock in a trauma patient.

Gastrointestinal stromal tumors (GISTs) are among the rare tumors of gastrointestinal (GI) tract. GISTs occur respectively in the stomach, small intestines, colon and rectum, omentum and mesentery, esophagus, retroperitoneal space, and abdominal cavity. However, they may occur anywhere along the GI tract. Typically, these tumors generally do not cause symptoms; however symptomatic patients may show stomach pain, GI bleeding, and palpable abdominal masses. These patients usually undergo surgery for obstruction symptoms or some other diagnosis. Our patient was admitted to the emergency department with acute abdomen and hypovolemic shock due to fall. The patient underwent emergency surgery, which revealed active bleeding from a stomach tumor showing an exophytic pattern of growth. This patient was a 32-year-old male, and blood tests revealed a white blood cell count of 23.500/mm³ and a hemoglobin level of 7.9 gr/dL. The heart rate was 110 beats/minute. The chest radiograph showed no subdiaphragmatic free air, and abdominal ultrasound showed impression of a mass that could not be distinguished from the liver, along with closed perforation or hemangioma. During the surgical procedure, 1200 cc of blood was suctioned, and the exophytic tumor was removed completely. Histological analysis of the tumor showed GIST, and it was considered to be a ruptured tumor by the oncology consultant. The patient was applied imatinib for 3 years after the surgery, and the disease did not re-occur during this period. Our goal in this case study is to emphasize that trauma may not be necessarily the cause of acute abdomen for emergency patients but that it also may be caused by hypotension-associated hypovolemic shock or other causes, bleeding from a GIST along with tumor torsion.

Erectile dysfunction after surgery for rectal cancer: a prospective study.

OBJECTIVES: Erectile dysfunction may occur as a complication of surgical treatment of rectal cancer in male patients. We compared the rates of postoperative erectile dysfunction and response to medical treatment after low anterior resection (LAR) and Miles' procedures. MATERIAL AND METHODS: Fifty patients who underwent the Miles' procedure or LAR were prospectively assessed. This study includes fifty patients with stages 1 and stage 2 rectal cancer based on clinical and radiologic assessments, who underwent Miles' (25 out of 50 patients underwent the Miles'procedure and ) or LAR (25 patients underwent LAR) procedures were prospectively assessed. The International Index of Erectile Function (IIEF) form was, used in the assessment to assess erectile dysfunction. This questionnaire, was administered preoperatively and 6 months postoperatively. For the patients with IIEF scores ≤ 25 at postoperative 6th months, tadalafil 5 mg is was given for 12 weeks and IIEF is was repeated after then. RESULTS: No significant differences were found in mean IIEF scores preoperatively (p= 0.695). In both groups, IIEF scores were significantly lower postoperatively compared with preoperatively (p= 0.00001, LAR; p= 0.00001, Miles'). Mean postoperative IIEF scores were significantly lower in patients who underwent Miles' compared with the LAR procedures (p= 0.0001). For patients with IIEF scores ≤ 25 at 6 months, tadalafil 5 mg was given for 12 weeks and IIEF scores were better in both groups (p= 0.00001). CONCLUSION: The erectile dysfunction rate after Miles' procedure was significantly higher than the rate of patients who developed erectile dysfunction after LAR surgery. We tried to emphasize that in after LAR surgery. We should not be concerned only with cancer treatment surgically in rectal tumour patients, but remember that situations affecting their social life, such as postoperative erectile dysfunction, have medical and psychologic importance.

[Reliability of ultrasonography for diagnosing acute appendicitis]. / Akut apandisitte ultrasonografinin güvenilirligi.

BACKGROUND: Abdominal ultrasonography (US) is the most commonly used diagnostic tool for diagnosing acute appendicitis, which is one of the most common causes of acute surgical abdomen. In this study, we examined the reliability of US for diagnosing acute appendicitis. METHODS: In this prospective study, we performed abdominal US on 235 patients admitted to our surgical emergency department during 2007 and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings. These patients were surgically treated by appendectomy, and the materials were pathologically examined. RESULTS: Two hundred thirty-five patients were admitted to this study. One hundred ninety-three of these patients (82.1%) were diagnosed as acute appendicitis, and 42 (17.9%) were diagnosed differently. One hundred thirty-three (88.67%) of 150 patients diagnosed as acute appendicitis on US examinations were also reported as acute appendicitis on histopathological examination. Sixty of 85 patients diagnosed differently on US examination were reported as acute appendicitis on histopathological examination. CONCLUSION: The sensitivity of abdominal US for diagnosing acute appendicitis was determined as 69%. The specificity was calculated as 60%, positive predictive value as 0.89, negative predictive value as 0.30, and accuracy as 0.67. Abdominal US is a helpful diagnostic tool for diagnosing acute appendicitis. However, it should not be seen as superior to anamnesis and physical examination findings.