Héctor Ortiz

Coloanal anastomosis : are functional results better with a pouch ?

PURPOSE: Different studies have shown that low colorectal and coloanal anastomosis often yield poor functional results. The aim of the present study was to investigate whether a colonic reservoir is able to improve functional results. METHODS: Thirty-eight consecutive patients subjected to low anterior resection were randomized following rectal excision in two groups. One (n=19) had a stapled straight coloanal anastomosis, and the other (n=19) had a 10-cm stapled colonic pouch low rectal anastomosis. Median anastomotic distance above the anal verge was 3.38±0.56 cm and 2.14±0.36 cm in both groups, respectively. Continence alterations, urgency, tenesmus, defecatory frequency, anal resting and maximum voluntary squeezing pressures, and maximum tolerable volume were evaluated one year later. RESULTS: One patient died of pulmonary embolism, and seven presented with a recurrence and were excluded from the study. Stool frequency was greater than three movements per day in 33.3 percent of cases with a reservoir and in 73.3 percent of those with a straight coloanal anastomosis (P<0.05). Maximum tolerable volume was significantly greater in patients with a reservoir (335 ± 195) than in those without (148 ± 38) (P<0.05). There were no significant differences in other variables studied. CONCLUSIONS: This study shows that some aspects of defecatory function after rectal excision could improve with a colonic reservoir.

Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano

The aim of this randomized study was to compare the results of anal fistula plug and endorectal advancement flap in the treatment of high fistula in ano of cryptoglandular origin.

Stapled Hemorrhoidopexy vs. Diathermy Excision for Fourth-Degree Hemorrhoids: A Randomized, Clinical Trial and Review of the Literature

PURPOSEThe aim of this prospective study was to compare the results of stapled hemorrhoidopexy with those of conventional diathermy excision for controlling symptoms in patients with fourth-degree hemorrhoids.METHODSThirty-one patients with symptomatic, prolapsed irreducible piles were randomized to either stapled hemorrhoidopexy (n = 15) or diathermy excision (n = 16). The primary outcome measure was the control of hemorrhoidal symptoms one year after operation.RESULTSThe two procedures were comparable in terms of pain relief and disappearance of bleeding. Recurrent prolapse starting from the fourth month after operation was confirmed in 8 of 15 patients in the stapled group and in none in the diathermy excision group: two-tailed Fisher’s exact test P = 0.002, RR 0.33, 95 percent confidence interval 0.19–0.59). Five of these patients responded well to a later conventional diathermy hemorrhoidectomy. Persistence of itching was reported in six patients in the stapled group and in one of the diathermy excision group (P = 0.03). On the other hand, six patients in the stapled group and none in the diathermy excision group experienced tenesmus (P = 0.007).CONCLUSIONSStapled hemorrhoidopexy was not effective as a definitive cure for the symptoms of prolapse and itching in patients with fourth-degree hemorrhoids. Moreover, stapled hemorrhoidopexy induced the appearance of a new symptom, tenesmus, in 40 percent of the patients. Therefore conventional diathermy hemorrhoidectomy should continue to be recommended in patients with symptomatic, prolapsed, irreducible piles.

Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano.

The length of follow‐up required after surgical repair of cryptoglandular fistula in ano has not been established. This prospective study determined the follow‐up time needed to establish that an anal fistula has been cured after elective fistulotomy or fistulectomy associated with endorectal advancement flap (ERAF) repair.

Sacral nerve stimulation for the treatment of faecal incontinence following low anterior resection for rectal cancer.

Aim  The aim of this study was to assess the effectiveness of sacral nerve stimulation (SNS) in the management of faecal incontinence following neoadjuvant therapy and low anterior resection (LAR) for rectal cancer.

Quality of mesorectum after laparoscopic resection for rectal cancer - results of an audited teaching programme in Spain.

Objective  The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer.

Consensus statementExperts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: Science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

Prospective study of artificial anal sphincter and dynamic graciloplasty for severe anal incontinence

Background and aimsDynamic graciloplasty and artificial anal sphincter are two options for refractory incontinence, the efficacy of which was compared in a prospective study.Patients and methodsBetween November 1966 and June 1998, 16 patients were operated on (artificial anal sphincter 8, dynamic graciloplasty 8). Four consecutive operations with each technique were performed by two colorectal surgeons (one initiated the study with the neosphincter and the other with dynamic graciloplasty). Two independent observers assessed postoperative results at 4-month intervals. Patients were followed up to January 2001, with a median (interquartile range) of 44 (13) months and 39 (15) months for the nesophincter and the dynamic graciloplasty, respectively.ResultsFourteen patients had complications. In the immediate postoperative period; there were eight cases of wound healing-related problems (four in the graciloplasty group). Perineal infection occurred in one patient in the graciloplasty group. At follow-up there were 11 complications (6 in the neosphincter group). Four patients undergoing neosphincter implantation had erosion or pain at the cuff site and had the implant removed (a new device was reimplanted in one). Four patients undergoing dynamic graciloplasty had the stimulator removed. Postoperatively the neosphincter was associated with a significantly lower score on the continence grading scale of the Cleveland Clinic Florida than graciloplasty.ConclusionThe artificial anal sphincter is a more convenient technique than dynamic graciloplasty for institutions treating small number of patients. However, technical failures and complications during follow-up that require reoperation are very high in both types of treatments.

Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy

The aim of this study was to compare quality of life of patients with chronic anal fissure before and after open lateral internal sphincterotomy.

Functional Outcome of Sacral Nerve Stimulation in Patients With Severe Constipation

BACKGROUND:Sacral nerve stimulation has been reported as an effective treatment for constipation. OBJECTIVE:This study aimed to evaluate the therapeutic efficacy of permanent sacral nerve stimulation on the treatment of idiopathic constipation resistant to medical and behavioral management over a median follow-up period of 25.6 (range, 6–96) months. DESIGN:A retrospective review of a prospectively maintained institutional review board-approved database was performed. SETTING:The study was performed at 2 tertiary-care European institutions with expertise in sacral nerve stimulation. PATIENTS:Patients were considered eligible if they had had symptoms for at least 1 year and if conservative treatment had failed. INTERVENTION:Patients were tested by percutaneous nerve evaluation before the procedure. If this evaluation was successful, patients underwent sacral nerve therapy with an implanted device. MAIN OUTCOME MEASURE:Patients were evaluated by means of a bowel function diary and the Wexner constipation score. RESULTS:A total of 48 consecutive patients (39 females, median age 50.0 years (range, 17–79 years) entered the study. Twenty-three patients were implanted with a permanent stimulator. On an intention-to-treat basis, only 14 of 48 patients (29.2%) met the definition of a successful outcome at the latest follow-up period (median, 25.6 (range, 6–96) months). The mean Wexner score decreased from 20.2 (SD 3.6) at baseline to 5.8 (SD 4.1) at the latest follow-up examination (p < 0.001). However, 6 of 14 patients (42.8%) were still using laxatives and/or enemas at the last follow-up. LIMITATIONS:The study was limited by the pragmatic approach necessary to evaluate the results in routine clinical practice. CONCLUSIONS:This study shows that sacral nerve stimulation has limited efficacy on an intention-to-treat basis as a routinely recommended therapy for intractable idiopathic constipation.