Replacement of internal ana sphincter.
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Anal Canal↗
Biomedical subjects
R Pietroletti
Publications and source records attributed to R Pietroletti.
Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation.
BACKGROUND: The STARR double stapling procedure (DSP), i. e. transanal anteroposterior rectotomy, has been recently reported as a low-morbidity and effective operation for the treatment of rectocele and internal rectal mucosal prolapse (R-IMP) causing obstructed defecation. We report the postoperative complications and recurrence of symptoms following this novel operation. PATIENTS AND METHODS: Fourteen chronically constipated women with RIMP, aged 36-72 years, presented with either severe complications or recurrence of symptoms following DSP performed by means of two circular staplers. All were followed for a median period of 12 months (range, 2-24) after DPS. RESULTS: Severe rectal bleeding occurred in two cases postoperatively. Persistent severe anal pain was reported by seven patients, all presenting with anxiety. Four of them were multiparous. Three patients had fecal incontinence, both had vaginal deliveries. R-IMP recurred in six, obstructed defecation in seven cases. Four patients needed reintervention, one for suturing the bleeding area, one excising the recurrent prolapse, one for colpocele and one for rectal stricture. Four patients required biofeedback training for non-relaxing puborectalis and two needed psychotherapy. CONCLUSION: Parity, spastic floor syndrome and psychoneurosis seem to be the risk factors predisposing to failure of DSP, which may be followed by severe complications and early recurrence of symptoms requiring reoperation.
Adult↗
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↗
Perianal acquired tufted angioma associated with pregnancy: case report.
Tufted angiomas are rare lesions described as slowly growing/spreading erythematous macules especially located in the upper trunk and neck. Herein we report the case of perianal location of a tufted angioma in a young pregnant woman. She came to our observation complaining of perianal pain accompanied by bleeding at defecation. A lesion resembling a perianal fissure was observed. Mild hypertonia of the internal sphincter was confirmed at manometry. After one week of ineffective medical treatment, surgery was planed at the end of the sixteenth week under local anaesthesia. The lesion was excised and a minimal sphincterotomy was performed; histopathology report described features of a tufted angioma. The pregnancy proceeded regularly, without anal symptoms, followed by normal vaginal delivery at the thirty-eighth week. This case showed three peculiar features: the association of tufted angioma and pregnancy, the perianal location, and the clinical appearance suggestive of an anal fissure. The clinical manifestation of a perianal tufted angioma, mimicking an anal fissure, is of utmost importance to the differential diagnosis and treatment plan, especially in a pregnant woman.
Adult↗
Combined pelvic floor rehabilitation.
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Biofeedback, Psychology↗
[Acute cholecystitis in patients over 70 years old].
BACKGROUND: Gallstone disease is the most common surgical indication in the elderly. Post-operative prognosis is severe in elderly with acute cholecystitis. Aim of this paper is to investigate the factors responsible for the severe prognosis and to detect how it could be improved. METHODS: One hundred fifty-seven patients, aged between 70 and 85 years (average 82 years), undergoing cholecystectomy between the years 1990 and 2000 have been studied; 65 patients (group A) had acute cholecystitis; 92 (group B) had uncomplicated gallbladder stones. RESULTS: Acute cholecystitis was the first symptom of gallstone disease in 69.2%. Laparocholecystectomy was performed in 31 cases (47.6%) of group A and in 58 cases (63.7%) of group B. In those cases with acute cholecystitis the postoperative morbidity (18.4%) was higher than in group B (1.0%), (A vs B: chi(2)=15.3; p<0.001). Similarly, postoperative mortality was higher (6.1% vs 1.0%; chi(2)=3.2; p<0.05) The severe postoperative prognosis was correlated significantly to index ASA (ASA II vs IV: chi(2)=7.0; p<0.001) but not to the technique adopted for cholecystectomy (VLC vs open: (chi)2=0.01; p=n.s.). The results obtained seem to confirm that the high incidence of postoperative complications in acute cholecystitis is due to the presence of associated diseases in elderly patients accompanied by the septic state. CONCLUSIONS: Early colecystectomy, in those cases with symptomatic, uncomplicated gallstone disease, might avoid severe postoperative prognosis in the elderly.
Acute Disease↗
Anaphylactic reaction caused by perianal application of glyceryl trinitrate ointment.
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Administration, Rectal↗
[The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit].
BACKGROUND: Inguinal hernioplasty represents one of the most frequently performed surgical operation. The recent introduction of prosthetic mesh made Bassini operation obsolete, with more space gained by the newly developed "tension-free" and "sutureless" surgical techniques. This new approach, however, results in increased initial costs for the hospital, due to the purchase of mesh materials. On the other hand a reduction of overall expenses for a single hernia repair should be expected. In this work an attempt is made to verify this, by calculating the cost-benefit ratio of different techniques for hernia repair. METHODS: The type and amount of materials used in a standard Bassini hernia repair, Lichtenstein and Trabucco have been examined. The amount of anesthetic drugs required, the average hospital stay and time away from work were recorded too. The costs of the three operations considered, not including routine expenses (operating room, bed sheet, etc.) have been estimated. RESULTS: Lichtenstein and Trabucco repair performed in local anesthesia (L. 1.354.120, L. 1.567.120) were cheaper than Bassini (L. 2.820.950). CONCLUSIONS: Since the system of diagnosis-related group offers a fixed amount of reimbursement for hernia repair (L. 3.247.000), the extensive use of tension free and sutureless methods, offers better profit for the Hospital. Last but not least, tension free hernia repair ensures short hospital stay, less postoperative pain, good compliance and better quality of life for the patient.
Cost-Benefit Analysis↗
[Risk indices in geriatric surgery: ASA index versus Reiss index].
The use of the Risk Index in surgery is aimed to plan surgical strategy in order to achieve a better postoperative prognosis. This is especially true in geriatric surgery where the ASA Index and, more recently, the Reiss Index are widely employed. Since the mentioned Risk Indices are calculated on the basis of different factors, in this study we compared the two Risk Indices with the aim of verifying which index offers better prognostic indications. 210 patients, aged over 70 years, undergoing surgical treatment, were investigated. The patients were grouped according to the ASA and Reiss Indices. The ASA Index showed good correlation only with postoperative mortality. The three classes of Reiss Index showed a significant correlation with the incidence of post-operative morbidity and mortality (p.o. morbidity: 7.1%, 21.5%, 30.3%; p.o. mortality; 1.7%, 9.2%, 24.2% -Chi 2 = 20.7; p < 0.001). Our results support the hypothesis that Reiss index offers better prognostic evaluation of postoperative outcome, suggesting its use in assessing postoperative prognosis in geriatric patients. In addition, our observation confirms the criticism reported of the ASA Index, merely considered as an indicator of health status regardless of surgical treatment. In conclusion, routine preoperative evaluation of the Reiss Index should be advised in geriatric patients with the aim to forecasting surgical risk in the first place, and them modifying operative strategy in order to improve postoperative results.
Age Factors↗
Primary gastroduodenal tuberculous infection presenting as pyloric outlet obstruction.
Gastroduodenal tuberculosis occurs in underdeveloped areas and, although rarely, also in western countries, affecting mainly immigrants, immunodepressed, or low socioeconomic classes. We report a case of gastroduodenal tuberculosis presenting as pyloric outlet obstruction. We describe the clinical features and the diagnostic approach to the patient, emphasizing the role played by surgery in the diagnosis and treatment of the established complication. Developments are needed in the diagnostic area (video-laparoscopy, polymerase chain reaction of mycobacterial DNA) and in the mini-invasive treatment of obstructive complications (endoscopic balloon dilatation, video-laparoscopic surgery).
Adult↗
Bowel stricture due to ischemic colitis: report of three cases requiring surgery.
The diagnosis of ischemic colitis is challenging and still based upon a high index of suspicion. We report here, three patients affected by ischemic colitis causing stenosis and intestinal obstruction that required surgical treatment. Results of surgery in the three cases were not fair reflecting the high mortality and morbidity rate of ischemic colitis. However, the three cases showed peculiar features allowing us to make a few speculative considerations. Better results in the treatment of ischemic colitis might be achieved by means of a prompt recognition of the initial picture and through a better control of the many associated diseases, that represent the main risk factor for the development of ischemic colitis itself and for the bad prognosis of surgical treatment.
Aged↗
[Intestinal obstruction caused by ischemic colitis: description of 3 surgically treated cases].
The diagnosis of ischemic colitis is challenging and still based upon a high index of suspicion. We report here, three patients affected by ischemic colitis causing stenosis and intestinal obstruction who required surgical treatment. Results of surgery in the three cases were not fair reflecting the high mortality and morbidity rate of ischemic colitis. However, the three cases showed peculiar features allowing us to make a few speculative considerations. Better results in the treatment of ischemic colitis might be achieved by means of a prompt recognition of the initial picture and through a better control of the many associated diseases, that represent the main risk factor for the development of ischemic colitis itself and for the bad prognosis of surgical treatment.
Aged↗
[Complications and results of surgical therapy in Crohn disease].
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Anti-Bacterial Agents↗
What happens to the rectal muscular cuff? An experimental study in dogs.
The anatomy and histology of the rectal muscular cuff was studied in 15 dogs with an ileal pouch-anal anastomosis. Eight channel, three-dimensional anal manometry showed normal maximal squeeze pressure (128 +/- 20 mm Hg) compared to a control group (135 +/- 4 mm Hg). The rectal muscular cuff showed complete absence of the cuff in three cases. In 12 dogs, the rectal cuff was retracted to a length of less than 1 cm, the muscle fibers were degenerated and fibrotic. The results in the canine model and the clinical results of patients with an ileal pouch-anal anastomosis with a cuff demonstrated that a rectal muscular cuff is not essential to maintain continence after ileal pouch-anal anastomosis.
Animals↗
Enteroglucagon and peptide Y-Y response after construction of a pelvic reservoir in humans.
The results of an investigation of plasma levels of gastrointestinal hormones in patients after the construction of a pelvic reservoir are reported. Enteroglucagon (EG) and peptide tyrosine-tyrosine (PYY), two hormones believed to play a relevant role in the adaptive response to bowel resection, were investigated using a specific radioimmunoassay in basal conditions and after a standard meal. Pouch patients showed a statistically significant increase in basal levels of both enteroglucagon and PYY compared with control subjects (P less than 0.02 and P less than 0.001, respectively). The response of enteroglucagon to food ingestion, evaluated by means of the total integrated response, was similar in patients and controls. Conversely, the response of PYY was significantly increased in pouch patients compared with control cases (P less than 0.02). Results of this investigation suggest that gut hormones may be involved in mediating the adaptive response of the intestine to pouch construction. Changes of gut peptides may explain, at least in part, the functional results observed after pouch construction.
Adult↗
Immunocytochemical study of endocrine cells in pelvic ileal reservoirs.
The distribution and morphology of intestinal endocrine cells was investigated in the mucosa of pelvic ileal reservoirs using immunocytochemical methods. Endoscopic biopsies were obtained from 15 patients after the construction of a modified J-pouch. The mucosa of the reservoir showed a variable degree of colonic metaplasia in all cases. No relevant quantitative variations of gut endocrine cells were detected, as revealed by immunostaining for the general marker, chromogranin, compared with normal ileal mucosa. Immunostaining for different peptide-containing cells resulted in normal number and morphology of serotonin, enteroglucagon, peptide tyrosine-tyrosine, and somatostatin-containing cells. Neurotensin cells were less numerous than in normal mucosa. The role played by gastrointestinal hormones in the adaptive response of the intestine to pouch construction is, presently, unclear. Further studies involving measurements of fasting and meal-stimulated levels of gut hormones in pouch patients might clarify this aspect.
Adult↗
[Changes in the prostanoid content and the population of endocrine cells in jejunal biopsies from celiac children].
Prostanoid content prostaglandin E2 (PGE2) and thromboxane B2 (TxB2) and endocrine cells population were evaluated in jejunal biopsies from celiac children; findings were compared to active celiac patients on a challenge diet. Patients were divided as follows: Group A: 14 children with active untreated celiac disease; Group B: 7 celiac children on gluten challenge who had received diet therapy for the past 2 years; Group C: 8 normal control children. Jejunal biopsies were used for endocrine cell population measurement by immunocytochemistry, using a specific marker (chromogranin), and for prostanoid radioimmunological evaluation. The quantitative assessment of the endocrine cell population in Groups A and B revealed a significantly higher number of endocrine cells (20 +/- 11.5; 18.4 +/- 9.8 n. cell/visual field respectively) compared to Group C (8.44 +/- 2.3 n. cell/visual field) (p less than 0.05). In the jejunal extract the PGE2 content (341.8 +/- 82.3) ng/g) for Group A biopsies was significantly higher than that of Group C biopsies (93 +/- 23 ng/g) (p less than 0.05. The PGE2 content (69.4 +/- +13.2 ng/g) for Group B did not show any statistically significant change. In contrast, TxB2 content in jejunal biopsies from all three groups was not significantly different.
APUD Cells↗
Early complications after surgery for Crohn's disease.
A group of 212 patients operated upon for Crohn's disease were studied and the early postoperative complications with related problems were assessed. The morbidity was 28.3 per cent, 60 patients had at least one complication, mainly of septic nature. The mortality was 3.3 per cent (7 patients), sepsis and deep vein thrombosis with pulmonary embolism were the most common causes of death. Postoperative complications were significantly higher (39.7%) (p less than 0.001) in patients with a pre-operative nutritional deficit and in those who had urgent surgery (44.4%) (p less than 0.001). Among patients with pre-operative sepsis, the morbidity was also higher (34.6%), but was not significant. Peri-anastomotic complications (dehiscence, abscess, fistula, bleeding) were apparently more frequent (45.4%) in patients with histological residual Crohn's disease at macroscopically free resection margins although this contrasts with previous series. A proper pre-operative diagnostic approach, adequate peri-operative protein-caloric repletion, antibiotic therapy, prevention of thromboembolism and elective surgery, are still the primary tools in reducing the morbidity and mortality after surgery for Crohn's disease.
Adolescent↗