Laparoscopic repair of perforated peptic ulcer: single-center results.

BACKGROUND: Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages. METHODS: From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A "laparoscopy-first" policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically. RESULTS: The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19-95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6%) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4%). The "conversion group" showed significant differences in ulcer size (larger ulcers: 1.9 vs. 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs. 0; p < 0.01), and MPI score (higher score: 24 vs. 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50-125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5%, and a mean hospital stay of 6.7 days (range 5-12 days). None of these patients required reintervention. CONCLUSIONS: The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.

Laparoscopic transcystic exploration for single-stage management of common duct stones and acute cholecystitis.

BACKGROUND: Common bile duct (CBD) stones are found in 10% of patients who undergo elective laparoscopic surgery for gallstone disease and in 10-20% of patients who present with acute cholecystitis (AC). For the latter, the role of laparoscopic transcystic exploration of the common duct (LTCE) as part of a single-stage procedure is still unknown. METHODS: This study, based on a "laparoscopy first" policy, included 201 subjects with cholecystocholedocholithiasis: 104 underwent a scheduled laparoscopic surgery (group A), and 97 where admitted for AC and had urgent laparoscopy (group B). Group B patients were significantly older (68.4 vs. 62.1 years; P = 0.0045), had a higher proportion of women (56% vs. 41%; P = 0.0345), and included more patients in the ASA III-IV class (39% vs. 21%; P = 0.0006). LTCE was performed by using basket-wired catheters. CBD clearance, operating time, conversion rate, morbidity and mortality, postoperative hospital stay, readmission, and residual CBD stones were the main outcome measures. RESULTS: Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B (P = not significant). Time spent in the operating room was longer for group B (175 vs. 141 min; P = 0.0003). There were no significant differences for postoperative hospital stay (group A 4.9 vs. group B 5.2 days), readmission rate (3.7% vs. 3.7%), and residual CBD stones (2.8% vs. 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7% vs. 4.6% and 28.7% vs. 16.8%, respectively), but differences were not significant. In group A, one patient died from MOFS. CONCLUSIONS: LTCE has proved to be a simple technique with a high yield of CBD clearance in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that patients with AC are more at risk for drawbacks.

Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature.

Gallbladder volvulus is a rare condition which can mimic an acute cholecystitis. This condition is characterized from a rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Preoperative diagnosis is difficult. This is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in the context of the available literature.

[Outcome of laparotomy for severe secondary peritonitis]. / La laparostomia nelle peritoniti secondarie severe.

BACKGROUND: Temporary abdominal closure with planned re-operations is a treatment method for several critical abdominal conditions. Aim of the study was to evaluate the effectiveness of laparostomy and the risk factors for survival in patients presenting with severe secondary peritonitis (SSP). METHODS: 52 patients (mean age 66.5) with a SSP were analyzed. The peritonitis developed spontaneously (n=34) or complicated a recent surgical operation (n=18). 18 patients were operated on for a bowel cancer and 6 of them had a metastatic disease. Skin closure (n=21), bogota bag (n=16) and vacuum-pack (n=15) were the methods employed to achieve temporary abdominal closure for planned re-operations. The severity of the disease was calculated by using APACHE II and Mannheim Peritonitis Index (MPI) scoring systems. Survival was the main outcome measure. RESULTS: Mortality was 38% (n=20). Age, sex, pathogenesis of the peritonitis, type of temporary abdominal closure, number of re-operations and occurrence of entero-atmospheric fistula did not differ significantly between survivors and nonsurvivors. APACHE II (19.6 vs. 14.3; p=. 0015) and MPI (35.5 vs. 27.8; p=. 001) scores were significantly greater in the non-survivors group. The occurrence of perforated left colon/rectum was also significantly greater among non-survivors. By multivariate analysis only MPI resulted to be a significant independent risk factor for survival (p < 0.05). CONCLUSIONS: SSP is a life-threatening condition. Laparostomy may have a role in controlling the source of abdominal infection but even with this outmost invasive surgical measure, mortality still remains high. For these patients, MPI may have a role as outcome predictor.

Gastrointestinal stromal tumour of the duodenum in childhood: a rare case report.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) are uncommon primary mesenchymal tumours of the gastrointestinal tract mostly observed in the adults. Duodenal GISTs are relatively rare in adults and it should be regarded as exceptional in childhood. In young patients duodenal GISTs may be a source of potentially lethal haemorrhage and this adds diagnostic and therapeutic dilemmas to the concern about the long-term outcome. CASE PRESENTATION: A 14-year-old boy was referred to our hospital with severe anaemia due to recurrent episodes of upper gastrointestinal haemorrhage. Endoscopy, small bowel series, scintigraphy and video capsule endoscopy previously done elsewhere were negative. Shortly after the admission, the patient underwent emergency surgery for severe recurrence of the bleeding. At surgery, a 4 cm solid mass arising from the wall of the fourth portion of the duodenum was identified. The invasion and the erosion of the duodenal mucosa was confirmed by intra-operative pushed duodenoscopy. The mass was resected by a full-thickness duodenal wall excision with adequate grossly free margins. Immunohistochemical analysis of the specimen revealed to be positive for CD117 (c-KIT protein) consistent with a diagnosis of GIST. The number of mitoses was < 5/50 HPF. Mutational analysis for c-KIT/PDGFRA tyrosine kinase receptor genes resulted in a wildtype pattern. The patient had an uneventful course and he has remained disease-free during two years of follow-up. CONCLUSION: Duodenal GISTs in children are very rare and may present with massive bleeding. Cure can be achieved by complete surgical resection, but even in the low-aggressive tumours the long-term outcome may be unpredictable.

Oncologic colon cancer resection in emergency: are we doing enough?

BACKGROUND: The primary challenge of surgery for colon cancer (CC) presenting as an emergency is the control of the complication but a proper oncologic technique should not be missed when bowel resection is feasible. Currently, recommended oncologic criteria include en-bloc resection of invaded organs and structures, an adequate extent of the bowel resection and of the free margins and an adequate number of lymph nodes yielded. METHODS: Chart-review of 499 CC patients undergone colectomy. One hundred and twenty-one (group A) presented as emergencies (obstruction n=85, perforation n=30, hemorrhage n=6) and were analyzed for tumor stage, need for enlarged resection, distal free margin, lymph node yield, mortality and morbidity. Results were compared with those observed in the 378 patients operated electively (group B). RESULTS: Group A patients had a more advanced cancer stage (stage III/IV 62.8% vs. 48.7%, p<.01), but the need for enlarged resection was not significantly different in the two groups. Also the length of free distal margin was similar (means, group A: 97 mm; group B: 84 mm, p=ns). The number of excised nodes was greater in emergency (means, group A: 26.2 nodes; group B: 20.8 nodes, p<.01). Compared with group B, emergency procedures resulted in higher morbidity (22.3% vs. 13.4%, p<.05) and mortality (8.2% vs. .8%, p<.0001). CONCLUSIONS: Recommended oncologic resection techniques may be applicable to surgery for complicated tumors of the colon and radical resection may be warranted by emergency colectomy. The worse long-term prognosis for patients with colonic cancer presenting acutely may be related to the stage of the disease rather than to the failure of surgery.

[The Aymand's hernia. Case report and review of the literature]. / L'ernia di amyand. Caso clinico e revisione della letteratura.

The crural hernia containing an inflamed appendix is a rare entity and must be considered a variant of the hernia first described in 1735 by Claudius Amyand. This hernia is rarely recognised and diagnosed before the surgical treatment because it is often confused with a strangled hernia. In spite of this, the clinical presentation seems to follow a well determined pathway, so is possible to argue that the uncorrect diagnosis is to be attributed to the ignorance of this hernia. We report a case of Amyand's crural hernia in a woman 57 years old. The base of the appendix was not inflamed and, according to this, we made an appendectomy. We closed the hernia defect without the use of a synthetic mesh. The post operative period was regular and free of complications.

[Hemorrhagic shock caused by iatrogenic aorto-cava injury. Case report]. / Shock emorragico da lesione iatrogena aorto-cavale. Case report.

INTRODUCTION: Vascular injuries during lumbar disc surgery vary between 1 and 5 per 10,000 disc operations and usually represent life-threatening events. MATERIAL AND METHODS: The authors present a case of aorto-iliac and ICY laceration during lumbar disc hernia repair, successfully treated with immediate damage control and direct suture, followed by endovascular procedure. CASE REPORT: A 34-year-old lady was operated on for a symptomatic disc herniation at L4-L5. Shortly after this procedure, an ipovolemic shock (IV degree) suddenly occurred with an evident abdominal distension. An emergent laparotomy in the same neurosurgery OR was then performed and revealed an active haemorrhage arising fJom an expansive retroperitoneal bleeding at the level of aorto-iliac bifurcation. After a proximal and distal damage control (manual compression plus aortic clamping) aortic and caval lacerations were repaired. An abdominal packing completed the procedure, due to the concomitant coagulopathy applied. At the second surgical look, carried out 24 hours after the first procedure, no active bleeding or vascular impairment were detected but an intraoperative US examination revealed a 3.5 cm wide right iliac pseudoaneurism confirmed by angioCT scan. This pseudoaneurism was later successfully treated with a double endovascular stenting. Postoperative outcome was uneventful and the patient was then discharged 11 days after the discectomy. Follow up study at 2 years did not demonstrate significant sequels. CONCLUSION: Although rare, vascular injuries during lumbar disc hernia surgery, are extremely severe complications, leading to high morbidity and mortality rates. In case of massive bleeding the presence of an "intrahospital" trauma team is a crucial factor for life-saving.

[Simultaneous laparoscopic treatment for common bile duct stones associated with acute cholecystitis. Results of a prospective study]. / Trattamento laparoscopico simultaneo per coledocolitiasi associata a colecistite acuta. Risultati di uno studio prospettico.

Laparoscopy for the management of acute cholecystitis has gained wide acceptance. Although it is well known that acute cholecystitis may be complicated by common bile duct stones in up to 15% of cases, to date there are no published studies addressing the management of common bile duct stones detected during laparoscopy for acute cholecystitis. We postulated that, when found, common bile duct stones associated with acute cholecystitis could be effectively and safety managed during the same laparoscopic procedure. We report on a five-year prospective study (2001-2005) involving 313 unselected patients who presented with a clinical diagnosis of acute cholecystitis (confirmed by specimen examination) and without any contraindication to laparoscopy. At surgery, transcystic cholangiograms were obtained in 289 (92%); the other 24 were excluded from the study. With an established diagnosis of common bile duct stones, attempts were made to clear the common bile duct by transcystic basket retrieval, ERCP or choledochotomy. Prevalence of common bile duct stones in acute cholecystitis, success of laparoscopic common duct clearance, conversion rate, operative time, morbidity, and postoperative hospital stay were the main outcome measures. Common bile duct stones were found in 63 pts (21.7%) presenting with acute cholecystitis. At laparoscopy, 12 patients (19%) required conversion to open surgery, 3 of these being due to failure to achieve common bile duct clearance. Common bile duct stones were cleared entirely laparoscopically in 51 patients (81%) by means of transcystic stone retrieval (38 pts, 75%), ERCP (12 pts, 23%) or choledocotomy (1 pt, 2%). At intention to treat analysis, patients undergoing cholecystectomy plus common bile duct clearance compared to those undergoing cholecystectomy alone, spent significantly more time in the operating theatre (mean 192 min vs 118 min, p < 0.001), needed open conversion more frequently (19% vs 6.1%, p = 0.0045), and had a higher overall morbidity rate (17.4% vs 4.4%, p = 0.015). The simultaneous procedure also adversely affected the postoperative hospital stay (mean 4.8 vs 3.4 days, p = 0.0164). Mortality was nil in both groups. The prevalence of common bile duct stones in patients presenting with acute cholecystitis should not be neglected. When common bile duct stones are found, clearance may be obtained laparoscopically in a substantial number of cases without any need for open surgery. The simultaneous laparoscopic approach for acute cholecystitis and common bile duct stones remains, however, a highly skilled and technically demanding procedure. Although a moderate incidence of drawbacks is observed, the results should be interpreted from the point of view of an all-in-one procedure that allows the patients to be cured without needing any further sequential interventions.

Giant epidermoid cyst of the spleen with carbohydrate and cancer antigen production managed laparoscopically.

True cysts of the spleen are rare; in a few cases, high serum levels of carbohydrate and cancer antigen have been reported. In such instances, cyst resection or splenectomy is indicated to rule out malignant lesions and to remove the cancer antigen producing epithelium. We report the case of a young woman with a symptomatic giant epidermoid cyst of the spleen. Due to the secreting epithelium lining the cyst, serum levels of CA 19-9 and CA 125 were elevated. Laparoscopic splenectomy achieved symptoms relief and and long-term normalization of serum tumor markers.

Giant aneurysm of the splenic artery in an elderly man short report and review of the literature.

UNLABELLED: Splenic Artery Aneurysms (SAAs) are usually single and small lesions, and their size rarely exceed 3 cm. In a review of the literature from 1950 to date, only 18 aneurysms defined as "giant" were found in 15 reported papers. CASE REPORT: A case of an 87-year-old man, successfully treated for a 7 cm wide aneurysm of the splenic artery is reported. Except for his age, the patient did not show any significant association with aneurysm-related diseases and was successfully submitted to en-bloc aneurysmectomy and splenectomy via open surgery.

The European experience with vascular injuries.

The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.

Applied electrophysiology of transposed muscle stimulation: practical considerations and surgical experience on graciloplasty for faecal incontinence.

Dynamic Graciloplasty has demonstrated to be a reliable option in the treatment of end-stage Faecal Incontinence with stable results after long-term evaluation studies. Continence restoration varies from 40 to 65% depending on incontinence etiology and surgical experience. In spite of that mechanisms of chronic electrostimulation, necessary to obtain muscular fiber conversion and increase contractile resistance to a prolonged stimulation still remains unfriendly to many colorectal surgeons. On the basis of pioneering experience on this field we examine the main critical aspects of electrostimulation, ranging from neurovascular bundle preparation to electrodes insertion and stimulation protocol application. The experience in the last 36 dynamic graciloplasties performed for Faecal Incontinence treatment is presented. A long-term success rate of 75% was achieved. Key features for a good postoperative contractile response were identified in a careful gracilis mobilization, in a meticulous identification of nervous pedicle and in the prudent early p.o. stimulation. Fibers conversion was obtained after a 10-11 weeks of training period with on/off stimulation in the majority of patients and battery life was significantly prolonged with a meticulous search of the lowest intraoperative stimulation thresholds. Early failures demonstrated to be linked mainly to postoperative septic complications, while long-term results were significantly related to the efficacy of muscular recruitment and in preoperative phase, to a careful patients selection.

Splenic abscess after splenic blunt injury angioembolization.

INTRODUCTION: Splenic Angioembolization (SAE), during Nonoperative Management (NOM) of Blunt Splenic Injury (BSI), is an effective therapy for hemodynamically stable patients with grade III, IV, and V OIS splenic injuries. We report a case of a patient with a blunt abdominal trauma due to an accidental fall, who presented splenic abscess a week after SAE and a review of the literature. CASE REPORT: A 38-year-old male arrived at Emergency after an accidental fall with contusion of the left upper quadrant of the abdomen. Abdominal CT scan revealed the fracture of the lower splenic pole with intraparenchymal pseudoaneurysms (OIS spleen injury scale IV). Considering the hemodynamic stability, NOM was undertaken and SAE was performed. After a week, the patient developed a splenic abscess confirmed by Abdominal CT; therefore, splenectomy was performed. There was no evidence of bacterial growing in the perisplenic hematoma cultures but the histological examination showed multiple abscess and hemorrhagic areas in the spleen. DISCUSSION: Splenic abscess after SAE during NOM of BSI is a rare major complication. The most frequently cultured organisms include Clostridium perfringens, Alpha-Hemoliticus Streptococcus, gram-positive Staphylococcus, gram-negative Salmonella, Candida, and Aspergillus. This case represents our first reported splenic abscess after SAE. CONCLUSION: SAE is a very useful tool for BSI managing; splenic abscess can occur in a short time, even if it is a rare major complication, so it may be useful to monitor patients undergoing SAE, focusing not only on the hemodynamic parameters but also on the inflammatory and infectious aspects.

The role of laparoscopy in adult bowel obstruction caused by intussusception.

AIM: The intestinal intussusception in the adult represent 1% of all occlusions. Organic causes are detectable in 90% of cases. Aim of this study is to discuss the diagnostic and therapeutic iter of adult intestinal intussusception with particular emphasis on role of laparoscopy. MATERIALS AND METHODS: We retrospectively considered 10 cases of intussusception between January 2000 and January 2013, demographic and clinical issue, location of invagination, the type of surgical treatment, the post-operative morbidity and mortality and histological nature of occlusion cause. RESULTS: Ten (F: M 1.5:1) patients were admitted in emergency with bowel obstruction, the median age was 50 years (r.18-91). All required surgical treatment. Three patients (30%) underwent a totally laparoscopic procedure, four patients (40%) laparoscopic exploration followed by laparotomy, three patients (30%) open surgery directly. The invagination was ileo-ileal (50%), ileo-colonic (40%) and colo-colonic (10%). Nine out of ten underwent to surgical resection. The malignancy was the most frequent cause. DISCUSSION: In case of colonic intussusception should not be performed any reduction because the frequent association with neoplastic disease. The laparoscopy can be safe and effective to allow, in entero-enteric and entero-colic intussusception, the definitive treatment of the occlusion. In the case of colo-colonic intussusception laparoscopy is a valuable diagnostic aid and can facilitate the later processing. CONCLUSION: The intestinal invaginations diagnosis can often be difficult. Laparoscopy is safe and effective in the diagnosis and treatment of adult intussusception.

Gene promoter methylation in colorectal cancer and healthy adjacent mucosa specimens: correlation with physiological and pathological characteristics, and with biomarkers of one-carbon metabolism.

We evaluated the promoter methylation levels of the APC, MGMT, hMLH1, RASSF1A and CDKN2A genes in 107 colorectal cancer (CRC) samples and 80 healthy adjacent tissues. We searched for correlation with both physical and pathological features, polymorphisms of folate metabolism pathway genes (MTHFR, MTRR, MTR, RFC1, TYMS, and DNMT3B), and data on circulating folate, vitamin B12 and homocysteine, which were available in a subgroup of the CRC patients. An increased number of methylated samples were found in CRC respect to adjacent healthy tissues, with the exception of APC, which was also frequently methylated in healthy colonic mucosa. Statistically significant associations were found between RASSF1A promoter methylation and tumor stage, and between hMLH1 promoter methylation and tumor location. Increasing age positively correlated with both hMLH1 and MGMT methylation levels in CRC tissues, and with APC methylation levels in the adjacent healthy mucosa. Concerning gender, females showed higher hMLH1 promoter methylation levels with respect to males. In CRC samples, the MTR 2756AG genotype correlated with higher methylation levels of RASSF1A, and the TYMS 1494 6bp ins/del polymorphism correlated with the methylation levels of both APC and hMLH1. In adjacent healthy tissues, MTR 2756AG and TYMS 1494 6bp del/del genotypes correlated with APC and MGMT promoter methylation, respectively. Low folate levels were associated with hMLH1 hypermethylation. Present results support the hypothesis that DNA methylation in CRC depends from both physiological and environmental factors, with one-carbon metabolism largely involved in this process.

Mesoappendix and appendix stump treatment in laparoscopic appendectomy: a retrospective study in 1084 patients.

BACKGROUND: Laparoscopic appendicectomy (LA) rapresents a standard but questionable approach in the treatment of acute appendicitis. The scope of this study is to show our experience using different methods in the mesoappendix and appendix stump treatment. MATERIALS AND METHODS: A retrospective analysis of all patient with acute appendicitis that underwent to LA was obtained. The results have been analysed compareing the single techniques used in the treatment of mesoappendix and appendix stump. RESULTS: The study included 1084 patients (M=648; F=436; mean age 28,4 years). During laparoscopic procedure we have founded in 296 cases a CAA (27.3%). The rate of conversion to open has resulted 3,2%; the mean operative time was 57,1'; mean postoperative stay was 2,7 days. Eighteen patients have experienced surgical complications. From our data, in the treatment of mesoappendix (Clip =863, bipolar coagulation = 165, stapler = 22) and the appendix stump (endoloop =784; stapler = 265) we found no statistically difference about postoperative stay, and incidence of IAA; the operative time was longer (54,2 vs 66' p<0.05) when the surgeon prefered stapling the appendix stump; but in this group there was a higher incidence of CAA (35.2 % vs 18.7%). CONCLUSIONS: Laparoscopic appendicectomy is safe and effective. We judge that there isn't a better technique than others but various options that should be evaluated taking care about costs, the experience of the surgeon and the degree of inflammation of the appendix.

Comparison study of MS-HRM and pyrosequencing techniques for quantification of APC and CDKN2A gene methylation.

There is increasing interest in the development of cost-effective techniques for the quantification of DNA methylation biomarkers. We analyzed 90 samples of surgically resected colorectal cancer tissues for APC and CDKN2A promoter methylation using methylation sensitive-high resolution melting (MS-HRM) and pyrosequencing. MS-HRM is a less expensive technique compared with pyrosequencing but is usually more limited because it gives a range of methylation estimates rather than a single value. Here, we developed a method for deriving single estimates, rather than a range, of methylation using MS-HRM and compared the values obtained in this way with those obtained using the gold standard quantitative method of pyrosequencing. We derived an interpolation curve using standards of known methylated/unmethylated ratio (0%, 12.5%, 25%, 50%, 75%, and 100% of methylation) to obtain the best estimate of the extent of methylation for each of our samples. We observed similar profiles of methylation and a high correlation coefficient between the two techniques. Overall, our new approach allows MS-HRM to be used as a quantitative assay which provides results which are comparable with those obtained by pyrosequencing.

Leiomyosarcoma of the right ovarian vein.

The case of a 70-year-old patient with a leiomyosarcoma of the right ovarian vein is presented. For this rare entity, complete surgical excision is believed to offer the best chance of cure.

Long-term efficacy of dynamic graciloplasty for fecal incontinence.

PURPOSE: Patients with end-stage fecal incontinence in whom all standard medical and surgical treatment has failed or is not expected to be effective can be treated by dynamic graciloplasty. The aim of this study was to review the long-term efficacy data. METHODS: Success was defined as a greater than 50 percent decrease in the frequency of incontinent episodes. Measured physiologic parameters included enema retention time and the difference in resting and squeezing pressures with and without stimulation. Measured quality-of-life parameters included the Medical Outcomes Study Short Form 36 Health Status Questionnaire, a Fecal Incontinence TyPE Specification, the Zung Self-Rating Depression Scale, the "state" portion of the State-Trait Anxiety Inventory, and the Visual Analog Scale, which were administered at baseline and through follow-up. Independent monitors collected data as part of a multicenter trial for patients who underwent dynamic graciloplasty from May 1993 to November 1999. RESULTS: There were 129 patients entered in the study, 115 of whom met eligibility criteria and were included in the efficacy outcome analysis. Twenty-seven patients entered the study with a preexisting functioning stoma; the remaining 88 patients did not have a functioning stoma at the time of enrollment. Success was achieved in 62 percent of nonstoma patients at 12 months; these results were sustained at 18-month and 24-month follow-up assessments (55 and 56 percent, respectively). The success rate in the stoma patients increased from 37.5 percent (9 of 24 patients) at 12 months to 62 percent (13 of 21 patients) at 18 months and was 43 percent at 24 months (9 of 21 patients), which reflects the increased number of patients whose stomas were closed. Although the measured physiologic continence parameters generally improved, these changes did not correlate with continence outcome. The group of patients (stoma and nonstoma) who underwent dynamic graciloplasty showed statistically significant improvements in quality of life as measured by Medical Outcomes Study Short Form 36 physical function (P = 0.006) and social functioning (P = 0.02) assessment. CONCLUSIONS: Dynamic graciloplasty was successful in the majority of patients with end-stage fecal incontinence. This result was usually achieved by 12 months after surgery in patients who did not have stomas and by 18 months in patients who had stomas at the time of dynamic graciloplasty surgery. These various improvements conferred by dynamic graciloplasty persisted during the two-year follow-up.