RESUMEN
Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.
Asunto(s)
Trastornos de Deglución , Reflujo Gastroesofágico , Laparoscopía , Adulto , Trastornos de Deglución/epidemiología , Trastornos de Deglución/etiología , Femenino , Fundoplicación , Reflujo Gastroesofágico/epidemiología , Reflujo Gastroesofágico/cirugía , Humanos , Laparoscopía/efectos adversos , Masculino , Calidad de Vida , Resultado del TratamientoRESUMEN
BACKGROUND: After initial enthusiasm in the use of a dedicated curved stapler (CCS-30 Contour Transtar) to perform stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS), difficulties have emerged in this surgical technique. OBJECTIVE: First, to compare surgeons' perception of difficulties of STARR performed with only Transtar versus STARR performed with the combined use of linear staplers and Transtar to cure ODS associated with large internal prolapse and rectocele; second, to compare the postoperative incidence of the urge to defecate between the 2 STARR procedures. DESIGN AND SETTING: An Italian multicenter randomized trial involving 25 centers of colorectal surgery. PATIENTS: Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated between January and December 2012. INTERVENTIONS: Participants were randomly assigned to undergo STARR with a curved alone stapler (CAS group) or with the combined use of linear and curved staplers (LCS group). MAIN OUTCOME MEASURES: Primary end-points were the evaluation of surgeons' perception of difficulties score and the incidence of the "urge to defecate" at 3-month follow up. Secondary end-points included duration of hospital stay, rates of early and late complications, incidence of "urge to defecate" at 6 and 12 months, success of the procedures at 12 months of follow-up. RESULTS: Of 771 patients evaluated, 270 patients (35%) satisfied the criteria. Follow-up data were available for 254 patients: 128 patients (114 women) in the CAS group (mean age, 52.1; range, 39-70 years) and 126 (116 women) in LCS group (mean age, 50.7 years; range, 41-75 years). The mean surgeons' perception score, was 15.36 (SD, 3.93) in the CAS group and 12.26 (SD, 4.22) in the LCS group (P < .0001; 2-sample t test). At 3-month follow-up, urge to defecate was observed in 18 (14.6%) CAS group patients and in 13 (10.7%) LCS group patients (P = .34; Fisher's exact test). These values drastically decrease at 6 months until no urge to defecate in all patients at 12 months was observed. At 12-month follow-up, a successful outcome was achieved in 100 (78.1%) CAS group patients and in 105 (83.3%) LCS group patients (P = .34; Fisher's exact test). No significant differences between groups were observed in the hospital stay and rates of early or late complications occurring after STARR. CONCLUSIONS: STARR with Transtar associated with prior decomposition of prolapse, using linear staplers, seems to be less difficult than that without decomposition. Both procedures appear to be safe and effective in the treatment of obstructed defecation syndrome resulting in similar success rates and complications.
Asunto(s)
Estreñimiento/cirugía , Obstrucción Intestinal/cirugía , Enfermedades del Recto/cirugía , Engrapadoras Quirúrgicas , Grapado Quirúrgico/métodos , Adulto , Anciano , Actitud del Personal de Salud , Estreñimiento/diagnóstico , Defecación/fisiología , Defecografía/métodos , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Obstrucción Intestinal/diagnóstico , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Enfermedades del Recto/diagnóstico , Rectocele/diagnóstico , Rectocele/cirugía , Recto/cirugía , Síndrome , Resultado del TratamientoRESUMEN
BACKGROUND: We hypothesized that pathological perineal descent may be responsible for the failure of operations for obstructed defecation syndrome and that correcting excessive perineal descent may improve the outcome in this group of patients. OBJECTIVE: The purpose of this study was to report the short-term preliminary results of a novel surgical procedure, transverse perineal support, for the correction of pathological perineal descent. DESIGN: This was a prospective, uncontrolled, open-label study. SETTINGS: The study was conducted in a hospital and a university center. PATIENTS: Among 25 patients observed with failure of previous surgery for obstructed defecation syndrome, 12 with pathological perineal descent underwent transverse perineal support, were followed-up at 6 months, and constituted the object of analysis. INTERVENTIONS: The surgical procedure was performed positioning a porcine dermal implant just above the perineum superficial fascia sutured to the periosteum membrane of ischiatic tuberosities at the insertion of the superficial transverse perineal muscle. MAIN OUTCOME MEASURES: The main outcome measures were obstructed defecation syndrome score and x-ray and magnetic resonance defecographic imaging evaluation of perineal descent and anorectal manometric parameters. RESULTS: The postoperative median obstructed defecation syndrome score was 7.0 (range, 3-8), showing a statistically significant difference if compared with the preoperative score of 13.5 (range, 9-18; p = 0.0005). The mean postoperative maximum intrarectal pressure was 69.4 ± 11.1 mm Hg, significantly higher than the preoperative pressure of 45.9 ± 12.8 mm Hg (p < 0.0001). At postoperative x-ray and magnetic resonance imaging defecography, the mean fixed and dynamic perineal descents were significantly lower than the preoperative descents (p = 0.02 for fixed perineal descent and p = 0.0004 for dynamic perineal descent). Of the 4 patients (33.3%) with preoperative pathological dynamic perineal descent, only 1 showed a persistent pathological dynamic perineal descent. No early or late complication was observed. LIMITATIONS: The study was limited by its small size and short follow-up time. CONCLUSIONS: Transverse perineal support appears to be a promising, safe, and effective procedure in the treatment of obstructed defecation syndrome associated with pathological perineal descent (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A225).
Asunto(s)
Estreñimiento/cirugía , Trastornos del Suelo Pélvico/cirugía , Perineo/cirugía , Adulto , Anciano , Colágeno/uso terapéutico , Estreñimiento/etiología , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Trastornos del Suelo Pélvico/complicaciones , Estudios Prospectivos , Reoperación , Síndrome , Resultado del TratamientoRESUMEN
Objective. This study was designed to evaluate the early results of the topical application of Hydrolyzed Hibiscus esculentus Extract 3% ointment (Myoxinol 3%), a novel local product with Botox-like activity, in the conservative treatment of chronic anal fissure (CAF). Methods. Among all patients with CAF observed during the study period, 31 subjects met the inclusion criteria and underwent medical therapy with Myoxinol 3% ointment every 12 hours for 6 weeks. Two patients were lost to follow-up. Clinical and manometric follow-up was carried out eight weeks after treatment. Results. At follow-up the success rate was 72.4% (21/29); median VAS score and mean anal resting pressure were significantly lower if compared with respective baseline data. The only one adverse effect of the topical application of Myoxinol 3% ointment was perianal itch, which was reported by 3,4% (1/29) of the patients available for the analysis. However, in this case this symptom did not cause interruption of the treatment. Conclusions. The topical application of Myoxinol 3% ointment in the cure of CAF shows encouraging early results. Further researches with a larger series and a longer follow-up are needed to confirm these data.
RESUMEN
PURPOSE: The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard. METHODS: From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results. RESULTS: A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively. CONCLUSION: 3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.
Asunto(s)
Enfermedades del Ano/diagnóstico por imagen , Endosonografía/métodos , Imagenología Tridimensional , Cuidados Preoperatorios , Sepsis/diagnóstico por imagen , Absceso/diagnóstico por imagen , Absceso/cirugía , Adulto , Enfermedades del Ano/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Fístula Rectal/diagnóstico por imagen , Fístula Rectal/cirugía , Sepsis/cirugíaRESUMEN
The use of a dedicated score represents an essential tool for the clinical staging of obstructed defecation syndrome (ODS), for subsequent diagnostic and therapeutic options, and for the evaluation of the results. This study was designed to develop and validate a new, simple, and disease-specific scoring system for ODS. The questionnaire consists of 5 items: excessive straining, incomplete rectal evacuation, use of enemas and/or laxatives, vaginal-anal-perineal digitations, and abdominal discomfort and/or pain. Each item was graded from 0 to 5 with a score ranging from 0 (no symptoms) to 20 (very severe symptoms). A specific statistical analysis identifies the new score as a valuable and concise instrument, which demonstrates, overall, excellent concurrent validity, reproducibility, internal consistency, and discriminant validity for the diagnosis and grading of ODS. The use of this questionnaire may improve uniformity in clinical research and may allow a more precise evaluation of symptom severity and treatment effectiveness in ODS.
Asunto(s)
Estreñimiento/diagnóstico , Estreñimiento/patología , Enfermedad Crónica , Cirugía Colorrectal/estadística & datos numéricos , Estreñimiento/tratamiento farmacológico , Estreñimiento/fisiopatología , Femenino , Humanos , Laxativos/uso terapéutico , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , SíndromeRESUMEN
PURPOSE: This multicenter randomized study was designed to compare the clinical and functional results of stapled transanal rectal resection (STARR) performed with 2 staplers (PPH-01 vs. PPH-03) in the treatment of hemorrhoidal disease associated with a large internal rectal prolapse. METHODS: From a total of 937 patients, referred for hemorrhoidal disease in the 20 centers involved in the study, 425 (45.3%) with prolapsed hemorrhoids associated with a large internal rectal prolapse were randomized to undergo STARR with PPH-01 or PPH-03. Postoperative evaluation was made at 3, 6, and 12 months. RESULTS: The incidence of bleeding at the stapled line was significantly lower in the PPH-03 group than in the PPH-01 group (58/207 [28.0%] vs. 145/201 [72.1%]; P < .0001); the mean number of hemostatic stitches was significantly higher in the PPH-01 than in the PPH-03 group (3.2 ± 0.1 vs. 1.8 ± 0.8; P < .0001). The mean operative time was 25.1 ± 11.5 minutes in the PPH-03 group and 38.1 ± 15.7 minutes in the PPH-01 group (P < .0001). No major complications occurred in either of the groups. At 12-month follow-up, the success rate in the 2 groups was 94.5% in the PPH01 group and 94.2% in the PPH03 group. CONCLUSION: STARR performed for the treatment of hemorrhoidal disease associated with a large rectal prolapse is a safe and effective procedure. The use of the PPH-03 stapler instead of the PPH-01 guarantees a statistically significant reduction of intraoperative bleeding and a significant decrease of the operative time.
Asunto(s)
Hemorroides/cirugía , Prolapso Rectal/cirugía , Engrapadoras Quirúrgicas , Grapado Quirúrgico/métodos , Adolescente , Adulto , Anciano , Distribución de Chi-Cuadrado , Femenino , Hemorroides/complicaciones , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Prolapso Rectal/complicaciones , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Stapled transanal rectal resection has become the primary surgical procedure for surgical treatment of obstructed defecation syndrome caused by rectocele or rectal intussusception. The procedure is generally performed with 2 circular staplers. Recently, a dedicated contour-curved stapler was developed. OBJECTIVE: This study was designed to compare the effects of these stapler types on relief of symptoms. DESIGN AND SETTING: A randomized controlled trial was conducted at a regional referral center in Naples, Italy. PATIENTS: Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated from November 2005 through September 2007. INTERVENTIONS: Participants were randomly assigned to undergo stapled transanal rectal resection with 2 circular staplers or the contour-curved stapler. MAIN OUTCOME MEASURES: The primary end point was success rate at 24 months, defined by symptom improvement on an obstructed defecation syndrome scale. Secondary end points included success rate at 12 months, Agachan-Wexner constipation score, and rates of early and late complications at 12 and 24 months. RESULTS: Of 198 patients evaluated, 63 patients (31.8%) satisfied criteria. Follow-up data were available for 61 patients: 30 patients (28 women) in the circular stapler group (mean age, 53; range, 41-75 years) and 31 (29 women) in the contour-curved stapler group (mean age, 55; range, 38-69 years). At 24-month follow-up, success was achieved in 21 patients (70.0%) with the circular staplers and in 27 (87.0%) with the contour-curved stapler (P = .10). Symptom scores improved significantly in both groups from baseline to 12 months (P < .0001). Improvement was maintained in the contour-curved stapler group: mean score, 5.0 (SD, 1.6) at 12 months and 5.5 (1.5) at 24 months (P = .20). In the circular stapler group, symptom scores worsened from 4.5 (1.5) at 12 months to 9.0 (1.3) at 24 months (P < .0001). At 24 months, the groups differed significantly in symptom scores (P < .0001) and constipation scores (P = .03). No significant differences were seen in duration of postoperative hospital stay or rate of early or late complications. CONCLUSIONS: Stapled transanal rectal resection with either circular or contour-curved staplers can achieve relief of symptoms in patients with obstructed defecation syndrome. The contour-curved stapler appears to result in more stable clinical results over time.
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Estreñimiento/cirugía , Intususcepción/cirugía , Rectocele/cirugía , Engrapadoras Quirúrgicas , Grapado Quirúrgico/métodos , Adulto , Anciano , Estreñimiento/etiología , Estreñimiento/fisiopatología , Femenino , Humanos , Intususcepción/complicaciones , Intususcepción/fisiopatología , Italia , Masculino , Manometría , Persona de Mediana Edad , Rectocele/complicaciones , Rectocele/fisiopatología , Síndrome , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM: Obstructed defaecation syndrome (ODS) represents a very common clinical problem. The aim of the this prospective multicenter study was to evaluate the efficacy and safety of stapler trans-anal rectal resection (STARR) performed by a new dedicated device, CCS-30 Contour Transtar, in patients with ODS caused by rectal intussusception (RI) and/or rectocele (RE). MATERIALS AND METHODS: All the patients who underwent STARR for ODS caused by RI and/or RE at Colorectal Surgery Units of S. Stefano Hospital, Naples, Gepos Hospital, Telese, Benevento and S. Maria della Pietà Hospital, Casoria, Naples, Italy were prospectively introduced into a database. Preoperatively, all the patients underwent anorectal manometry and cinedefecography. The grade of ODS was assessed using a dedicated obstructed defaecation syndrome score (ODS-S). All the patients with a ODS-S >or=12 and RI and/or RE were enrolled. Patients were followed up clinically at 6 months. RESULTS: Thirty patients, 28 (93.3%) women, mean age 56.6+/-12.7 years, underwent STARR, by Transtar, between February and October 2006. Preoperatively, ODS-S was 15.8+/-2.4. RI was present in 26 (89.6%) and RE (34.4+/-15.2 mm) in 27 (93.1%) patients. No major postoperative complications occurred. The length of hospital stay was 2.5+/-0.6 days. At 6-month follow-up, ODS-S was 5.0+/-2.3 (P<0.001). Successful outcome was achieved in 25 (86.2%) patients. CONCLUSION: STARR, performed by the new dedicated device, CCS-30 Contour Transtar, seems to be an effective and safe procedure to treat ODS caused by RE and/or RI. A longer follow-up and a larger number of patients is needed to confirm these results.
Asunto(s)
Estreñimiento/cirugía , Defecación/fisiología , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Intususcepción/complicaciones , Rectocele/complicaciones , Recto/cirugía , Técnicas de Sutura/instrumentación , Adulto , Anciano , Estreñimiento/diagnóstico , Estreñimiento/etiología , Defecografía , Femenino , Estudios de Seguimiento , Humanos , Intususcepción/diagnóstico , Intususcepción/fisiopatología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Enfermedades del Recto/complicaciones , Enfermedades del Recto/diagnóstico , Enfermedades del Recto/fisiopatología , Rectocele/diagnóstico , Rectocele/fisiopatología , Suturas , Síndrome , Resultado del TratamientoRESUMEN
PURPOSE: This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure. METHODS: All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months. RESULTS: Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 +/- 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 +/- 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001). CONCLUSIONS: As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence.