G. Del Genio

Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study

PURPOSEPneumatic balloon dilation has been shown to be effective in the management of chronic anal fissure, but its effect on the anal sphincter has not been fully investigated. The aim of this study was to evaluate prospectively the clinical, anatomic, and functional pattern in a group of patients treated by pneumatic balloon dilation.METHODSA series of 33 consecutive patients suffering from chronic anal fissure underwent pneumatic balloon dilation. Anal manometry and ultrasonography were performed prior to and 6 to 12 months after the treatment. Manometry was accomplished by means of an endoanal 40-mm balloon inflated with a pressure of 1.4 atmospheres that was left in situ for six minutes under local anesthesia. All patients were interviewed daily for three days after surgery and then clinically evaluated between the third and fifth postoperative weeks. Most patients were interviewed after 25.7 ± 8.4 months (mean ± standard deviation). Anal incontinence was evaluated by means of a validated score of 1 to 6.RESULTSThe chronic anal fissure healed between the third and fifth weeks in 31 patients (94 percent), who became asymptomatic 2.5 ± 1.4 days after pneumatic balloon dilation. None of them reported anal pain two years after the treatment (n = 20). The first post-pneumatic balloon dilation defecation was painless in 27 cases (82 percent). Two multiparous females (6 percent of the patients) complained of minor transient anal incontinence (score, 3). Chronic anal fissure recurred in one case (3 percent) after treatment. At manometry, the preoperative anal resting pressure decreased from 91 ± 11.2 to 70.5 ± 5.6 and to 78 ± 5.7 mmHg, 6 and 12 months after pneumatic balloon dilation, respectively (P < 0.0001). Anal ultrasonography did not show any significant sphincter defect.CONCLUSIONSPneumatic balloon dilation seems to be an effective, safe, easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage.

Influence of esophagealmotility on the outcome of laparoscopic total fundoplication

The aim of this study is to evaluate if esophageal dysmotility can influence the outcome of laparoscopic total fundoplication for gatro-esophageal reflux disease (GERD). The advent of laparoscopic fundoplication has greatly reduced the morbidity of antireflux surgery and by now, it should be considered the surgical treatment of choice for GERD. Some authors assert that total versus partial fundoplication should improve the rate of postoperative dysphagia or gas bloat syndrome, particularly in patients with esophageal dysmotility. From September 1992 to December 2005, 420 consecutive patients 171 male and 249 female, mean age 42.8 years (range 12-80) underwent laparoscopic Nissen-Rossetti fundoplication. At manometric evaluation, we divided patients into two groups: group A (163/420; 38.8%) with impaired esophageal peristalsis (peristaltic waves with a pressure < 30 mmHg), and group B (257/420; 61.2%) without impaired peristalsis. We followed up clinically 406 out of 420 (96.7%) patients, 156/163 patients (95.7%) in group A and 250/257 patients (97.3%) in group B. An excellent outcome was observed in 143/156 (91.7%) group A patients and in 234/250 (93.6%) group B patients (P = NS). Both groups showed significant improvement in clinical symptom score with no statistically significant difference between patients with normal and impaired peristalsis. Thus, preoperative defective esophageal peristalsis is not a contraindication to total laparoscopic fundoplication.

Useful parameters helping proctologists to identify patients with defaecatory disorders that may be treated with pelvic floor rehabilitation

BackgroundNo studies have specifically reported on the use of a diagnostic tool based on physiatric assessment of constipated or incontinent patientsMethodsSixty-seven constipated and 37 incontinent patients were submitted to a standard protocol based on proctologic examination, clinico-physiatric assessment (puborectalis contraction, pubococcygeal test, perineal defence reflex, muscular synergies, postural examination) and instrumental evaluation (anorectal manometry, anal US and dynamic defaecography). Patients were offered pelvic floor rehabilitation (thoraco-abdominoperineal muscle coordination training, biofeedback, electrical stimulation and volumetric rehabilitation).ResultsAfter rehabilitation treatment, decreases of Wexner constipation score (p=0.0001) and Pescatori incontinence score (p=0.0001) were observed.ConclusionThis diagnostic protocol might improve the selection of patients with defaecatory disorders amenable for rehabilitation treatment.

Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature.

Background and Aims: While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors’ experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen–Rossetti fundoplication. Material and Methods: From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45–74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen–Rossetti fundoplication. Results: The mean operative time was 135 min (range = 105–190 min). Mean hospital stay was 14.2 days (range = 7–25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6–192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%). Conclusions: Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH)

This study aims to evaluate by the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII-pH. MII-pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII-pH are warranted to check at a longer follow-up for the efficacy of this antireflux procedure in achalasic patients.

Crura ultrastructural alterations in patients with hiatal hernia: a pilot study

BackgroundLaparoscopic fundoplication for gastroesophageal reflux disease (GERD) and hiatal hernia has been validated worldwide in the past decade. However, hiatal hernia recurrence still represents the most frequent long-term complication after primary repair. Different techniques for hiatal closure have been recommended, but the problem remains unsolved. The authors theorized that ultrastructural alterations may be implicated in hiatal hernia. Thus, this study was undertaken to investigate the presence of these alterations in patients with or without hiatal hernia.MethodsSamples from Laimer–Bertelli connective membrane and muscular crura at the esophageal hiatus were collected from 19 patients with GERD and hiatal hernia (HH group), and from 7 patients without hiatal hernia enrolled as the control group (NHH group). Specimens were processed and analyzed by transmission electron microscopy.ResultsMuscle and connective samples from the NHH group did not present any ultrastructural alteration that could be detected by transmission electron microscopy. Similarly, connective samples from the HH group showed no ultrastructural alterations. In contrast, all muscle samples from the HH group exhibited sarcolemmal alterations, subsarcolemmal vacuolar degeneration, extended disruption of sarcotubular complexes, increased intermyofibrillar spaces, and sarcomere splitting.ConclusionThe evidence of ultrastructural alterations in all the patients in the HH group raises the suspicion that the long-term outcomes of antireflux surgery depend not only on the surgical technique, but also on the underlying muscular diaphragmatic illness.

Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders.

PurposeThe aims of this study were to evaluate several clinical and instrumental parameters in a large number of patients with constipation and incontinence as well as in healthy controls and discuss their potential implications in the functional aspects of these disorders.MethodsEighty-four constipated and 38 incontinent patients and 45 healthy controls were submitted to a protocol based on proctologic examination, clinico-physiatric assessment, and instrumental evaluation.ResultsConstipated and incontinent patients had significantly worse lumbar lordosis as well as lower rate in the presence of perineal defense reflex than controls. Constipated but not incontinent patients had a lower rate of puborectalis relaxation than controls. Furthermore, worse pubococcygeal tests and a higher rate of muscle synergies presence, either agonist or antagonist, were observed in both constipated and incontinent patients compared to controls.ConclusionsThis study has demonstrated strong correlations between physiatric disorders and the symptoms of constipation and incontinence. Further studies designed to demonstrate a causal relationship between these parameters and the success of a specific treatment of the physiatric disorders on the proctology symptoms are warranted.

Total Fundoplication Does Not Obstruct the Esophageal Secondary Peristalsis: Investigation with Pre- and Postoperative 24-Hour pH-Multichannel Intraluminal Impedance

Aim: To determine the impact of total fundoplication on the spontaneous esophageal clearance, known as secondary peristalsis. Background: Although there is general agreement that total fundoplication is not an obstacle to bolus swallowing (primary peristalsis), whether it is an obstacle to spontaneous esophageal clearance (secondary peristalsis) is still not clear. Based on 24-hour monitoring, multichannel intraluminal impedance was used to calculate the time of spontaneous bolus clearance (BCT). Methods: Mean BCT was prospectively calculated in 15 consecutive patients before and after total fundoplication. BCT was calculated in seconds including all the gastroesophageal reflux episodes, whereas bolus swallows (solid meals and liquid swallows) were excluded from the analysis. Results: BCT was extrapolated from 1,057 episodes in the 623 h of study. Overall, BCT did not change after surgery (13.6 ± 4 vs. 15.2 ± 10 s; p = nonsignificant) and in the upright (12.2 ± 3 vs. 16.5 ± 7 s; p = nonsignificant) and recumbent position (22.9 ± 9 vs. 23.0 ± 9 s; p = nonsignificant). Conclusions: In this study total fundoplication did not affect the BCT by combined 24-hour ph monitoring and multichannel intraluminal impedance.

Mesorectum, is it an appropiate term?

Dear Editor, In this letter, we make some considerations about the use of the term mesorectum. Although the term mesorectum is widely used to define the perirectal fat tissue surrounding the rectum, we raise some doubt whether it is appropriate or not. This can stimulate the experts to reconsider the term and find a more appropriate definition. During the last 20 years, oncologic surgery of the rectum has undergone a remarkable evolution, especially thanks to some Anglo-Saxon surgeons. Thanks to their efforts, the importance of the en bloc excision of the diseased rectum together with the surrounding adipose environment and the perirectal lymph nodes, wrapped in a thin envelope that represents an important barrier to neoplastic dissemination especially during surgical manipulation, was established. This procedure, to be carried out in a meticulous way, has to recognise and to respect the pelvic nervous plexus, thus limiting functional complications. The improved knowledge about the biological characteristics of the neoplasia and about the way it spreads has contributed to drastic reduction of abdominoperineal excisions and overall a better long-term survival and quality of life. The distal limit of resection reduced to 1–2 cm, the reconstruction of intestinal continuity extended to the anorectal junction and the techniques of sphincter preservation and nerve sparing represent the most important achievement of the evolution of this type of surgery. This achievement, reported by Heald in 1982 but already described by Valdoni who applied it to abdominoperineal excision, has contributed to an increased knowledge and to a better standardisation of a correct procedure for rectal excision. The importance of the socalled mesorectum lays in the fact that it contains a conspicuous lymphatic perirectal network with lymphatic channels, which drain directly into the lymph nodes. The number of lymph nodes in this structure may vary between 4 and 8 in our own data, but it may reach the number of 12 according to Pocard’s data. From a surgical point of view, the importance of excising en bloc the rectum together with its mesorectum is manly due to the reduction of local recurrences. Nonetheless, our idea is that the term mesorectum, reported for the first time by Mansell, may be inaccurate on the basis of our modern knowledge. Our statement is supported by anatomical, embryological and functional considerations. The anatomical reason is that the term “meso”, as defined by Morgado, can be attributed only to those peritoneal folds that, having wrapped the bowel and its vessels for a portion, are anchored to the posterior abdominal wall thus suspending the bowel and allowing it mobility (as for transverse mesocolon and mesosigmoid). An exception is the mesocolon of the ascending and descending colon in which the posterior peritoneal fold is atrophic secondary to direct contact with the posterior abdominal wall where it is substituted by the so-called Int J Colorectal Dis (2007) 22:1127–1128 DOI 10.1007/s00384-007-0290-2