Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period.

PURPOSE: Gracilis muscle transposition (GMT) is an established surgical technique in the treatment of anorectal fistulas and fistulas to the vagina and the urinary system when previous closure options have failed. There is little evidence on the success rate of this procedure in the long term. METHODS: This is a follow-up study on all patients undergoing GMT over a 10-year period at a tertiary referral center for complex fistulas. Postoperative function and quality of life were evaluated by standardized questionnaires (Wexner score, Fecal Incontinence Quality of Life Score (FIQL), SF-12 and a brief questionnaire designed for this study). Sexual function was evaluated by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function. RESULTS: Forty-seven gracilis muscle transpositions (GMT) in 46 patients were performed. Most treated patients had (neo-)-rectovaginal fistulas (n = 29). An overall fistula closure was achieved in 34 of 46 patients (74%): in 25 cases primarily by GMT (53%) and in nine patients with persistent or recurrent fistula by additional surgical procedures. A clinically apparent relapse occurred on average 276 days (median: 180 days) after GMT (mean follow-up 73.4 months). CONCLUSION: GMT in our hands has a primary closure rate of 53%, and after further procedures, this rises to 74%. Fecal continence is impaired in patients having undergone GMT. The overall quality of life in patients after GMT is only slightly impaired, and sexual function is severely impaired in female patients.

Laparoscopic ventral mesh rectopexy in complex pelvic floor disorder.

AIM: For the treatment of complex pelvic organ prolapse, many different surgical procedures are described without any comparative studies available. Laparoscopic ventral mesh rectopexy after D'Hoore is one of the methods, which is publicized to treat patients with symptomatic rectocele, enterocele and rectal prolapse. METHOD: All patients who received ventral mesh rectopexy since 07/10 for symptomatic rectocele, enterocele and possible rectal prolapse I ° or II ° in terms of a complex pelvic floor disorder were included in this follow-up study. The Wexner score for incontinence was recorded (range 0-20), the constipation score of Herold (r6-30) was evaluated as well as supplementary questions compiled by D'Hoore concerning outlet symptoms (r0-20). In addition, the quality of life (SF-12) was requested. RESULTS: Thirty-one women were operated in the period, and 27 were eligible to be included in the present study. Median follow-up was 22 months (2-39). The preoperative Wexner score was in median 8 (0-20), going down to 6 (0-20) without significance (p = 0.735). The constipation score decreased significantly from median 14 (9-21) to 11 (6-25) (p = 0.007). The median score after D'Hoore was preoperatively 8 (4-16) and 4.5 (0-17) postoperatively (p = 0.004). The SF-12 values were preoperatively significantly reduced compared to the normal population; postoperatively, they equalized. CONCLUSION: Two years after laparoscopic ventral mesh rectopexy, constipation and quality of life improve significantly in patients with complex pelvic organ prolapse. The grade of incontinence remains essentially the same, but was not the dominant clinical problem in the treated patients of our study. STATEMENT: The improvement in constipation and quality of life after laparoscopic ventral mesh rectopexy for obstructive defecation is encouraging. However, the impact on sexual life differs; some patients improve but a relevant number reports a change for the worse.

Long-term functional outcome of colonic resections: how much does faecal impairment influence quality of life?

AIM: Older data suggest that colonic resection has a negative impact on continence and quality of life. The aim of this study was to evaluate the functional outcome of colonic resections for colonic cancer and diverticulitis and its influence on quality of life. METHODS: Patients who underwent colonic resection between 2005 and 2013 were identified from a prospective database. A survey with two questionnaires [Faecal Incontinence Quality of Life (FIQL) scale, Short Form 12 (SF-12)] and additional questions concerning bowel function was sent to all patients. RESULTS: Colonic resection was performed in 362 patients in the study period; 297 patients returned the questionnaires (response rate 82.0%). Faecal urgency or incontinence more than once a month was present in 15% of patients and 25% of patients reported that bowel symptoms limited their quality of life. The mean total FIQL score for all patients was 3.58. The SF-12 score was comparable to a reference population without prior colonic resection. Patients after right-sided resections had liquid stool more often than others (45.3% vs 38.7%, P = 0.011). No differences in bowel function and quality of life were detected between resections for colonic cancer and diverticulitis. CONCLUSION: Most patients experience no limitation in bowel function after segmental colectomy. Those with limitations in bowel function still seem to cope well, as the quality of life is not severely affected. Nevertheless, most patients with lower functional scores also had lower quality of life scores. Whether surgery is a relevant factor has to be questioned, as the prevalence of faecal incontinence in a comparable population without prior surgery is almost identical.

A randomised, multi-centre, prospective, observer and patient blind study to evaluate a non-absorbable polypropylene mesh vs. a partly absorbable mesh in incisional hernia repair.

BACKGROUND: The implantation of a polymer mesh is considered as the standard treatment for incisional hernia. It leads to lower recurrence rates compared to suture techniques without mesh implantation; however, there are also some drawbacks to mesh repair. The operation is more complex and peri-operative infectious complications are increased. Yet it is not clear to what extent a mesh implantation influences quality of life or leads to chronic pain or discomfort. The influence of the material, textile structure and size of the mesh remain unclear. The aim of this study was to evaluate if a non-absorbable, large pore-sized, lightweight polypropylene (PP) mesh leads to a better health outcome compared to a partly absorbable mesh. METHODS/DESIGN: In this randomised, double-blinded study, 80 patients with incisional hernia after a median laparotomy received in sublay technique either a non-absorbable mesh (Optilene® Mesh Elastic) or a partly absorbable mesh (Ultrapro® Mesh). Primary endpoint was the physical health score from the SF-36 questionnaire 21 days post-operatively. Secondary variables were patients' daily activity score, pain score, wound assessment and post-surgical complications until 6 months post-operatively. RESULTS: SF-36, daily activity and pain scores were similar in both groups after 21 days and 6 months, respectively. No hernia recurrence was observed during the observation period. Post-operative complication rates also showed no difference between the groups. CONCLUSION: The implantation of a non-absorbable, large pore-sized, lightweight PP mesh for incisional hernia leads to similar patient-related outcome parameters, recurrence and complication rates as a partly absorbable mesh.

Management and outcome of anastomotic leakage after colonic surgery.

AIM: Anastomotic leakage remains a key factor for morbidity after colonic surgery. The aim of the study was to analyse the outcome of different therapeutical approaches. METHOD: Of 1731 consecutive patients undergoing colonic resection between 1998 and 2005 at our institution, 67 patients with anastomotic leakage were identified from a prospective database. A logistic regression model was used to determine factors which influenced the therapeutic approach and outcome. RESULTS: The overall anastomotic leakage rate was 3.5%. All patients were re-operated. The anastomosis was resected without restoration of continuity in 31 but preserved in 36 patients. An ileostomy was constructed in 27 of 36 patients with anastomotic leakage after repair or revision of the anastomosis, the remaining nine cases were treated without ileostomy. Five of these latter nine vs three of the 27 patients with ileostomy experienced re-leakage (P = 0.05). The overall mortality was 25%. The Mannheim Peritonitis Index was 17.44 for survivors vs 25.64 for nonsurvivors (P < 0.001). Restoration of intestinal continuity was performed in 95% of the patients with ileostomy and in 88% after Hartmann's procedure. Multivariate analysis identified multi organ failure as the only factor predictive of a fatal outcome (P < 0.001). An ASA-score of more than 2 (P = 0.02) and peritonitis (P = 0.002) were reasons for not preserving the anastomosis. CONCLUSION: Repair or redo of the anastomosis without a protective ileostomy frequently results in failure of the procedure. After Hartmann's operation or split stoma creation a majority of patients undergo restoration of intestinal continuity.

[Laparoscopic resection of a giant colon diverticulum : Case report and review of the literature]. / Laparoskopische Resektion eines Riesenkolondivertikels : Fallbericht und Literaturübersicht.

BACKGROUND: Giant diverticula are rare complications of diverticular disease. Current opinion regards operative therapy as the method of choice for the treatment of symptomatic giant diverticula; however, there is neither consensus about the technique nor about the necessary extent of resection. Based on a non-systematic review of the literature, an overview of giant diverticula in terms of epidemiology, pathology and classification is given. The current case is considered with respect to appropriate diagnostic procedures and possible therapeutic options. CASE PRESENTATION: An 80-year-old female patient presented to the emergency department with abdominal pain and dyspnea. A computed tomography scan showed a large gas-filled structure in the upper left abdomen adjacent to the left colon. A giant colonic diverticulum was suspected and laparoscopy was performed. Intraoperatively, the diagnosis of a giant colon diverticulum located at the splenic flexure was confirmed. An unremarkable diverticulosis only was found in the descending colon. The giant diverticulum was treated by an atypical colon wedge resection and the postoperative course was uneventful. DISCUSSION: This case report describes a laparoscopic atypical colon wedge resection as treatment of a giant colon diverticulum. Only four laparoscopic bowel resections in terms of sigmoid resections or hemicolectomy with primary anastomosis have been reported. Minimally invasive surgery can be a valuable alternative to open procedures. In the current case a laparoscopic atypical colon wedge resection was safely performed. This option might be considered as an alternative to extended resections of giant diverticula. Localization of the giant diverticulum and the simultaneous existence of diverticular disease are the main criteria for the decision between the different operative approaches.

Phylogenetic signal and its decay in mitochondrial SSU and LSU rRNA gene fragments of Anisoptera.

The phylogeny of Anisoptera, dragonflies in the strict sense, has proven to be notoriously difficult to resolve. Based on morphological characters, several recent publications dealing with the phylogeny of dragonflies proposed contradicting inter- and intrafamily relationships. We explored phylogenetic information content of mitochondrial large-subunit (LSU) and small-subunit (SSU) ribosomal gene fragments for these systematic problems. Starting at published universal primers, we developed primer sets suitable for amplifying large parts of the LSU and SSU rRNA genes within dragonflies. These fragments turned out to harbor sufficient phylogenetic information to satisfyingly resolve intrafamily relationships, but they contain insufficient phylogenetic structure to permit reliable conclusions about several interfamily relationships. We demonstrate that decay of phylogenetic signal progresses from intrafamily to interfamily to outgroup relationships and is correlated with an increase of genetic distances. As expected, signal decay is most pronounced in fast-changing sites. Additionally, base composition among fast-changing sites significantly deviates from the expected homogeneity. Homogeneity of base composition among all included taxa was restored only after removing fast-changing sites from the data set. The molecular data tentatively support interfamily relationships proposed by the most recent publication based on morphological characters of fossil and extant dragonflies.

An empirical analysis of mt 16S rRNA covarion-like evolution in insects: site-specific rate variation is clustered and frequently detected.

The structural and functional analysis of rRNA molecules has attracted considerable scientific interest. Empirical studies have demonstrated that sequence variation is not directly translated into modifications of rRNA secondary structure. Obviously, the maintenance of secondary structure and sequence variation are in part governed by different selection regimes. The nature of those selection regimes still remains quite elusive. The analysis of individual bacterial models cannot adequately explore this topic. Therefore, we used primary sequence data and secondary structures of a mitochondrial 16S rRNA fragment of 558 insect species from 15 monophyletic groups to study patterns of sequence variation, and variation of secondary structure. Using simulation studies to establish significance levels of change, we found that despite conservation of secondary structure, the location of sequence variation within the conserved rRNA structure changes significantly between groups of insects. Despite our conservative estimation procedure we found significant site-specific rate changes at 56 sites out of 184. Additionally, site-specific rate variation is somewhat clustered in certain helices. Both results confirm what has been predicted from an application of non-stationary maximum likelihood models to rRNA sequences. Clearly, constraints on sequence variation evolve and leave footprints in the form of evolutionary plasticity in rRNA sequences. Here, we show that a better understanding of the evolution of rRNA sequences can be obtained by integrating both phylogenetic and structural information.