Anal sphincter replacement: the solution to a problem?
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Anal Canal↗
Biomedical subjects
G Dodi
Publications and source records attributed to G Dodi.
Complications after stapled hemorrhoidectomy: can they be prevented?
Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. A review of 1,107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1,107) complication rate. Immediate complications (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%). Even though SH appears to be promising, we feel that a multicenter randomized study with a long-term follow-up comparing SH and banding is necessary before recommending the procedure. Most complications can be avoided by respecting the rectal wall anatomy in the execution of the procedure.
Adult↗
Neuromodulation for fecal incontinence: outcome in 16 patients with definitive implant. The initial Italian Sacral Neurostimulation Group (GINS) experience.
PURPOSE: Sacral nerve modulation appears to offer a valid treatment option for some patients with fecal incontinence and functional defects of the internal anal sphincter or of the striated muscle. METHODS: Sixteen patients with fecal incontinence (4 males; mean age, 51.4 (range, 27-79) years) with intact or surgically repaired (n = 1) anal sphincter underwent permanent sacral nerve stimulation implant. Cause was traumatic in two patients, and associated disorders included scleroderma (2 patients) and spastic paraparesis (1 patient); eight (50 percent) of the patients also had urinary incontinence, and two (12.5 percent) had nonobstructive urinary retention. All patients were selected on the basis of positive findings from at least one peripheral nerve evaluation. The stimulating electrode was positioned in the S2 (1 patient), S3 (14 patients), or S4 (1 patient) sacral foramen. RESULTS: Mean follow-up was 15.5 (range, 3-45) months. Mean preimplant Williams score decreased from 4.1 +/- 0.9 (range, 2-5) to 1.25 +/- 0.5 (range, 1-2) (P = 0.01, Wilcoxon test), and the number of incontinence accidents for liquid or solid stool in 14 days decreased from 11.5 +/- 4.8 (range, 2-20) before implant to 0.6 +/- 0.9 (range, 0-2) at the last follow-up. Important manometric data were an increase in mean maximal pressure at rest of 37.7 +/- 14.9 mmHg (implantable pulse generator 49.1 +/- 18.7, P = 0.04) and in mean maximal pressure during squeeze (prestimulation 67.3 +/- 21.1 mmHg, implantable pulse generator 82.6 +/- 21.0, P = 0.09). CONCLUSIONS: Neuromodulation can be considered an option for fecal incontinence. However, an accurate clinical and instrumental evaluation and careful patient selection are required to optimize outcome.
Adult↗
Multicentre retrospective analysis of the outcome of artificial anal sphincter implantation for severe faecal incontinence.
BACKGROUND: A new prosthetic device, the Action artificial anal sphincter, has recently been introduced for treating severe faecal incontinence. The results of this procedure in 28 patients are presented. METHODS: The patients underwent operation for severe faecal incontinence in four Italian university hospitals and patients were reviewed after a median follow-up of 19 (range 7-41) months. RESULTS: Early infections occurred in four patients, requiring removal of the device in three. Dehiscence of the perineal wound occurred in nine patients. After activation of the device, the cuff had to be removed in a further four patients (for rectal erosion in two, anal pain in one and late infection in one). The cuff was accidentally broken in one patient. A new anal cuff was repositioned successfully in two patients. Overall, five patients had complete removal of the device and two removal of the cuff only. Twenty-one patients available for long-term evaluation had a major improvement in faecal continence. Median resting anal pressure increased from 27 mmHg before surgery to 32 mmHg after operation. Preoperative squeeze pressure was 42 mmHg while maximum postoperative anal pressure with the activated device was 67 mmHg. The median American Medical System incontinence score decreased significantly from 98.5 to 5.5 (P < 0.001). Similar figures were observed using the Continence Grading Scale (from 14.9 to 2.6; P < 0.001). Twelve patients developed symptoms of obstructed defaecation while two patients complained of anal pain. CONCLUSION: Improved continence was achieved after neosphincter implantation in three-quarters of the patients. Early infection and rectal erosion, together with difficulty in evacuating, are still major concerns with this technique.
Adult↗
Does surgery resolve outlet obstruction from rectocele?
In order to ascertain whether plastic surgery for rectocele is of value in the treatment of outlet obstruction, a retrospective study was made of 21 women complaining of difficulty in expelling faeces: 13 patients (group A) underwent surgery with transanal longitudinal plication of the anterior rectal wall (Block's technique), and 8 patients (group B) had colpoperineoplasty which, in 2, was associated with bladder-neck suspension following the Raz-Peyrera technique for urinary incontinence. The mean follow-up was 24.2 +/- 18.7 and 36.8 +/- 17.8 months respectively. In 11 group A patients (80.9%) and 6 group B patients (75%) cure, or an improvement, was achieved. Of the remaining 4 patients (19%), recurrent rectocele was found in 2 (one group A and one group B) and intestinal transit time tests detected colonic constipation in one group A and in one group B patient. It is concluded that surgery can resolve outlet obstruction from rectocele, but Block's technique is preferable because it is more straight-forward and easier.
Constipation↗
Does acetylsalicylic acid interfere with stimulated pancreatic secretion? An experimental study in the rat.
To evaluate the effect of the prostaglandin inhibitor acetylsalicylic acid (ASA) on rat exocrine pancreas secretion, three groups of rats were administered ASA by infusion: Groups 1-3, 50, 100, and 200 mg/kg body wt, respectively; Group 4 received saline. Twenty minutes later these ASA-pretreated groups were given intraarterial secretin (18 CU/kg) and cholecystokinin (CCK) (18 micrograms/kg). In an additional three groups of seven rats each, saline solution rather than secretin-CCK was given after ASA pretreatment. Pancreatic juice was collected every 10 min by means of a chronic pancreatic fistula. Bicarbonate and protein concentrations were measured and variations in outputs observed. No significant variations were found in the bicarbonate concentrations and outputs of rats with different types of pharmacological treatment, while protein concentrations and outputs were found to vary with time and type of experiment. There was, however, no interaction between these two variables. At lower ASA dosages, the bicarbonate and protein concentrations and outputs of secretin-CCK-stimulated rats were higher than the basal values and the levels of rats without hormonal stimulation. At higher dosages, no difference was found between the two groups. In conclusion, ASA seems to interfere with stimulated pancreatic exocrine secretion of proteins, even when its effect on bicarbonate concentration is factored in, and its effect seems to be present at the highest dosages considered in the study. Among the various hypotheses that may explain this phenomenon, an antagonizing effect of ASA on secretin-CCK action should be the first to be considered.
Animals↗
Multiple rubber band ligation after one loading of instrument.
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Hemorrhoids↗
Can proctological procedures resolve perianal pruritus and mycosis? A prospective study of 23 cases.
Twenty-three patients with pruritus ani associated with anal mycosis underwent primary treatment of a concurrent anal disorder. The anal disorders included haemorrhoids (n = 9), fissure (n = 8), anal spasm without fissure (n = 5), and occult mucosal prolapse (n = 1). Pretreatment investigation of faeces for parasites was negative. The glucosal tolerance test and white blood cell count were normal in all cases. Culture of skin smears from the perianal region was positive for Candida only in 16 patients, Dermatophytes only in 6 and a combination of both in 1 patient. Following the appropriate proctological procedure, pruritus resolved or markedly improved in 20 patients. The remaining three patients required antifungal treatment with econazole. Two of these, however, continued to complain of pruritus. It is suggested that in patients with pruritus ani associated with perianal mycosis, antimycotic therapy should be used only if fungal infection persists after treatment of the underlying proctological disease.
Adolescent↗
Disposable torch-lit anoscope.
A disposable torch-lit anoscope is described. Its bevelled end facilitates therapeutic procedures, while the fact that it does not need an external light source makes its use on the ward or in the patient's home more straight-forward.
Anal Canal↗
Role of proctography in severe constipation.
As referred to in the literature, patients complaining of constipation may have a spastic or, in the case of chronic staining, weak pelvic floor. Twenty-two severely constipated patients who did not improve after a high fiber diet were submitted to whole gut transit time (TT), proctographic, and anorectal manometric studies. A control group consisting of five subjects for TT, five subjects for proctogram, and ten subjects for manometry was also studied. Transit time was delayed (P less than 0.001) in all patients. Manometry in the constipated group showed a high rectal threshold (64.1 vs. 17.1 ml of air, P less than 0.01), but no other significant difference. Proctograms in 10 of 22 patients (Group A) showed no differences in the anorectal angle (ARA) and in its distance from the pubococcygeal line (DLPC) in respect to the control group; 12 of 22 patients (Group B) had a paradoxical closure of the ARA at straining in respect to resting position (101.2 degrees vs. 120.1 degrees), and a higher DLPC than Group A and the control group in all positions studied. There was no difference in TT for rectal stasis of radiopaque markers between the two pathologic groups. Patients in Group B were older than patients in Group A (55.3 vs. 42.9 years, P less than 0.05). In conclusion, proctograms showed alterations of the pelvic floor, but there was no correlation between protographic data and rectal or colonic stasis of the radiopaque markers, or clinic severity of constipation, but a correlation between ages did exist.
Adolescent↗
Failure of secretin to exert an ameliorative effect on acute reflux pancreatitis in the rat.
This study was undertaken to evaluate the possible ameliorative effect of secretin on acute reflux pancreatitis in the rat. Thirty days after the performance of a gastrojejunal anstomosis, in all rats (36 Sprague-Dawley, mean weight 250 g) acute pancreatitis was induced by creating a closed duodenal loop for 12 h. In the subsequent 12 h group A (14 rats) received continuous intra-arterial infusion of secretin (5 CU/kg/h); group B (22 rats) received equal volumes of saline solution. Serum amylase and pancreatic histology were evaluated. In group B a mild form of pancreatitis was observed, since the mean values of haemorrhage, necrosis and steatonecrosis, indices of severe disease, were found to be low. Group A presented similar results. No difference was documented between the two groups for both the histological findings and serum amylase. We can conclude that despite the reported protective and ameliorative effects of secretin in cerulein-induced acute pancreatitis in the rat, our data do not support a similar action of secretin in the closed duodenal loop model.
Acute Disease↗
Does bile play a fundamental role in inducing and influencing acute reflux pancreatitis in rat?
Acute pancreatitis by closed duodenal loop in two groups of rats, with or without biliary diversion, was induced to ascertain any role that bile might have in codetermining and influencing the disease. Both the histological findings and the serum amylase levels showed the presence of mild acute pancreatitis in both groups. The histological and/or biochemical findings and the survival rates were similar for rats with and rats without biliary diversion. We may therefore conclude that the closed duodenal loop causes acute pancreatitis of a mild degree in the rat; bile did not appear to play a fundamental role in inducing or in influencing the outcome of the acute pancreatic inflammation in this experimental model.
Acute Disease↗
Lipid metabolism in lipoatrophic diabetes.
Some aspects of lipid metabolism were studied in 4 patients with a congenital lipoatrophic diabetes (LAD) associated to a type IV hyperlipoproteinemia. The analysis of lipoprotein composition, expressed as mg/dl, demonstrates a significant increase of VLDL mass and a significant reduction of HDL mass. The analysis of lipoprotein composition, expressed as per cent of total mass demonstrates an increase of the triglyceride content in all fractions and a significant reduction of the cholesterol and phospholipid content in HDL2 particles. Apo C-II, C-III0, C-III1 and C-III2 levels in lipoprotein fractions were normal in LAD patients. Lipoprotein lipase activity in omental adipose tissue, collected during laparoscopy in one patient was undetectable. The serum of this patient did not fully activate the lipoprotein lipase eluted from normal adipose tissue. In all patients the adipose tissue lipoprotein lipase activity in post-heparin plasma was blunted or near absent. Thus a reduced peripheral clearance of triglyceride-rich lipoprotein could be an important determinant of lipoprotein abnormalities in lipoatrophic diabetes.
Adipose Tissue↗
Combined determination of serum CA 19-9 and tissue polypeptide antigen: why no improvement in pancreatic cancer diagnosis?
CA 19-9 and tissue polypeptide antigen (TPA) were determined in the sera of 28 control subjects, 29 patients with pancreatic cancer, 26 with chronic pancreatitis and 62 with benign and malignant extra pancreatic diseases in order to compare their usefulness in diagnosing pancreatic cancer, to verify whether the combined assessment of the two indices could improve the results given by a single parameter and to speculate on the role of liver dysfunction in increasing their serum levels. The sensitivity, specificity and accuracy of CA 19-9 and TPA in diagnosing pancreatic malignancy were: 76, 85 and 61% for CA 19-9 and 79, 52 and 32% for TPA. The receiver-operating characteristic curves showed that CA 19-9 and TPA similarly discriminate pancreatic cancer from controls and chronic pancreatitis, while CA 19-9 is more useful than TPA in differentiating pancreatic malignancy from benign and malignant extra pancreatic abdominal diseases. TPA did not seem to add further information as compared to CA 19-9 alone when both markers were combined. Liver dysfunction may contribute to increasing serum levels of both markers.
Antigens, Neoplasm↗
Visceral obesity and diabetes.
The cross-sectional subcutaneous and visceral areas of adipose tissue, measured on computed tomographic scans at abdominal level and the subcutaneous/visceral fat area ratio (S/V ratio) distribution have been calculated in 155 subjects. Using the S/V ratio as discriminator, two groups of patients of both sexes, with subcutaneous or visceral type of obesity have been selected. Metabolic studies demonstrate a significant reduction of glucose tolerance at the oral glucose load and a significant increase of the insulin response in patients with visceral obesity. The size of the omental fat cells was larger in visceral obesity, while the size of subcutaneous fat cells was larger in subcutaneous obesity. A significant correlation was found between the S/V area ratios and the subcutaneous/visceral fat cell weight ratios. In vitro studies on subcutaneous and omental fat obtained during surgery from 9 patients with subcutaneous obesity and 7 patients with visceral obesity demonstrate a significantly higher isoprenaline-stimulated lipolytic response in omental fat of patients with visceral obesity. The lipoprotein lipase activity in subcutaneous fat was higher than in omental fat in both types of obesity.
Adipose Tissue↗
Ribonucleases and deoxyribonucleases in pancreatic cancer: clinical value and pathophysiological interrelationships.
In this study we evaluated some pathophysiological aspects of pancreatic and liver ribonucleases and alkaline deoxyribonuclease and their clinical usefulness in diagnosing pancreatic cancer. Pancreatic RNase was found to be a sensitive index of pancreatic malignancy; however it was not specific in distinguishing pancreatic malignancy from chronic pancreatitis or other pathologies. Liver RNase and alkaline DNase did not provide better results than pancreatic RNase. These three enzymes were found to be age-dependent and related to each other. Therefore serum nucleases are not useful for clinical purposes since they are influenced, at least in part, by different non-specific factors.
Biomarkers, Tumor↗
[Radiologic diagnosis of anal fistulae with radio-opaque markers].
Fistulography classifies anal fistulas in low-below puborectalis muscle-, high-above puborectalis muscle-, and middle. This classification increases the scope and accuracy of radical surgery. In order to improve the diagnostic reliability of anal fistulography the authors point out the importance of radio-opaque markers for anatomical definition of the anorectal region. Thirty patients (25 males and 5 females; mean age: 47 years) were studied by anal fistulography using radiopaque markers: a Foley's 22 Fr catheter, with distal balloon filled of idrosoluble radiopaque contrast medium, was placed in the anal canal; a metal marker was fixed to the anus. In order to demonstrate the relationship between fistula and puborectalis muscle, we subdivided the anal canal in 3 equal segments: high, middle and low. The idrosoluble contrast medium for fistulography is injected through a pediatric Foley's catheter 8 Fr when external opening is large enough, and through a K7072 endovenous catheter when the opening is small. Fistulous tract was visible in all patients: internal fistulous opening in 23/90 cases, and relationship of fistulous tract to puborectalis muscle in 25/30 (83.3%). In demonstrating either secondary fistulous tracts or abscesses, fistulography with radiopaque markers was correct in 60% of cases; in 20% of patients some of the above-mentioned complications were demonstrated, and in the 20% no complications at all were detected.
Adult↗
Ureteroduodenal fistula.
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Duodenal Diseases↗