Treatment of chronic anal fissures and associated stenosis by autologous adipose tissue transplant: a pilot study.

PURPOSE: A substantial body of recent evidence suggests that autologous adipose tissue transplant promotes healing in different lesions associated with local ischemia. We report the outcome of lipoaspirate transplant in hard-to-treat chronic anal fissures. METHODS: Eight patients were included in this pilot study, 5 with single and 3 with multiple fissures. All had intense anal pain and had previously undergone proctologic surgery, with internal sphincterotomy performed in 6 patients. Severe stenosis was present in 3 patients and moderate stenosis in 2. Preoperative assessment included anoscopy, anorectal manometry, colonoscopy, and microbiological tests to exclude inflammatory, neoplastic, or infectious diseases. Surgical treatment consisted of transplant of purified autologous fat retrieved from the hypogastrium. Follow-up was scheduled after 1 week, at 2, 3, 6, and 12 months, and thereafter on a yearly basis. RESULTS: All of the patients were discharged several hours after surgery. No early postoperative complication was observed. Complete healing and pain remission were achieved in 6 patients (75%), 4 of whom were treated in a single session, whereas 2 patients required 2 and 3 sessions. Anal stenosis was resolved in 4 of 5 patients (80%). The therapy was unsuccessful in 2 patients (25%). Mean follow-up was 18 months (range, 3-36 months). CONCLUSION: Perianal autologous fat transplant can be safely performed for the treatment of complex anal fissures. It is well tolerated and offers encouraging results, although further research is warranted because of the small number of patients treated and the relatively short follow-up time.

Long-term outcome of sacral nerve stimulation for fecal incontinence.

PURPOSE: Sacral nerve stimulation is a safe and effective procedure for fecal incontinence. We investigated whether its efficacy is maintained long term. PATIENTS AND METHODS: Sixty patients with fecal incontinence underwent permanent sacral nerve stimulation. Patients' data were prospectively recorded in the national registry of the Italian Group of sacral nerve stimulation. The severity of fecal incontinence was evaluated by the Wexner score, and data were collected in a bowel function diary. Quality of life was evaluated by the Italian version of the Medical Outcomes Survey Short Form (SF-36) questionnaire. RESULTS: Fifty-two patients were available for long-term follow-up lasting at least 5 years. Compared with baseline, the Wexner score decreased significantly after definitive implantation (from 15 +/- 4 to 5 +/- 5, P < 0.001). At least 50 percent improvement in continence was achieved in 74 percent of the patients, and at least 70 percent improvement (median value) was achieved in 50 percent. The mean number of solid/liquid incontinence episodes decreased significantly from 0.5 (+/-0.5) to 0.1 (+/-0.3) per day (P = 0.004). Quality of life improved in all domains. The overall mean improvement in SF-36 scores was 39.8 percent. Both mean resting and squeeze anal pressures increased significantly, and maximum volume tolerated decreased significantly. CONCLUSIONS: Sacral nerve stimulation maintains its efficacy long term, not only in regard to control of symptoms but also regarding quality of life.

Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain?

BACKGROUND: Chronic idiopathic anal pain is a common, benign symptom, the etiology of which remains unclear. Traditional treatments are often ineffective. This study investigated the efficacy of sacral nerve stimulation in treating chronic idiopathic anal pain. METHODS: Twelve patients (10 women and 2 men; mean age, 61.0 +/- 10.3 years; range, 48-82 years) implanted with a permanent device for sacral nerve stimulation were followed in the Italian Group for Sacral Neuromodulation (GINS) Registry. All patients had frequent chronic anal or perianal pain; 75 percent had previously undergone pelvic surgery. Pharmacologic and rehabilitative therapy had yielded poor results. Changes from baseline to last follow-up examination were evaluated for scores on a visual analog pain scale (0-10) and the Short-Form 36 (SF-36) health status questionnaire. Manometric measurements recorded at last follow-up were compared with preimplantation values. RESULTS: In one patient, the permanent device was removed because of technical failure. After a mean follow-up of 15 (range, 3-80) months, visual analog pain scores had significantly improved (from 8.2 +/- 1.7 to 2.2 +/- 1.3, P < 0.001). SF-36 physical component scores increased from 26.27 +/- 5.65 to 38.95 +/- 9.08, P < 0.02). Scores on the mental component showed improvement, although not significant. Postimplantation changes in manometric functional data were not significant, but sensitivity thresholds showed a considerable decrease. CONCLUSIONS: Long-term follow-up data showing improvements in scores on the visual analog pain scale and quality of life questionnaire indicate that, before adopting more aggressive surgical procedures, SNS should be considered for patients with chronic idiopathic anal pain in whom pharmacologic and biofeedback treatments have failed to produce effective results.

[Anorectal manometry: standardisation of the execution technique]. / La manometria anorettale: standardizzazione della tecnica di esecuzione.

Anorectal manometry is the basic investigation for the study of anorectal function. The lack of a standard execution technique and of any common definition of the manometric parameters constitutes a major limitation. The aim of the present study is to propose a standard technique for performing manometry. In addition we also focus on those manometric parameters that are easily identified and interpreted for the systematic study of a proctological patient. The protocol used is organised in three phases: (i) tests with a radial channel probe with continuous extraction, which provide information on the length of the anal canal and on the precise site of maximum pressure; (ii) tests with a radial channel probe with stationary extraction, which does not involve reflex contraction of the sphincter apparatus and therefore permits better evaluation of sphincter pressure when the muscles are relaxed as well as the identification of slow and ultra-slow waves; (iii) tests with a helicoidal probe and a balloon for the evaluation of the anorectal inhibitory reflex and of anorectal sensitivity. Using this protocol it is possible to perform manometry in less than 30 minutes and to define the importance of anorectal function with approximately 10 parameters which are easily identified and interpreted.

Surgical excision of developmental retrorectal cysts: results with long-term follow-up from a single institution.

Developmental cysts are very rare lesions occurring in the retrorectal space, and include epidermoid, dermoid, tailgut cysts and teratomas. There is little information on their natural history and biologic behavior, although a recent paper reported a greater incidence of malignant transformation than previously thought. The diagnosis requires high-resolution imaging, and complete surgical excision is the treatment of choice. In this paper we analyzed short- and long-term results of surgical excision of six retrorectal developmental cysts observed at our institution over a period of 11 years. All patients were women, three were referred with an infected perineal fistula/pelvic abscess after having undergone drainage surgery elsewhere. In these three patients, excision was attempted through a trans-perineal approach, which was technically demanding and ultimately incomplete because of the intense surrounding inflammation. Multiple re-interventions were required for tumor recurrence, and two of them still present an occasional perineal discharge. In the other three patients, a trans-perineal or trans-anal route was employed according to tumor location, without any recurrence at a median follow-up of 118.5 months. Final pathologic diagnosis included five tailgut cysts and one teratoma. This paper shows that the treatment of developmental cysts may be very challenging, especially when they are associated with a concomitant fistula/abscess and are not correctly diagnosed at presentation. In our experience, healing was finally achieved in four patients out of six. All the lesions were benign, and no malignant transformation was observed during follow-up, even in tumors partially resected.