Michał Romaniszyn

Doppler-Guided Hemorrhoid Artery Ligation with Recto-Anal-Repair Modification: Functional Evaluation and Safety Assessment of a New Minimally Invasive Method of Treatment of Advanced Hemorrhoidal Disease

Purpose: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). Methods: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. Results: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. Conclusions: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

Successful implantation of autologous muscle-derived stem cells in treatment of faecal incontinence due to external sphincter rupture

Dear Editor:The most common pathological mechanism of faecalincontinence is the insufficiency of the external anal sphinc-ter (EAS) caused by neurological or myogenic dysfunction.The myogenic mechanism of EAS insufficiency is usuallydue to direct mechanical damage during childbirth, traumaor surgery in anorectal region, whereas neurologicalaetiology involves either spinal or peripheral nerves disrup-tion—in most cases the pudendal nerve. Unfortunately, co-incidence of sphincter rupture with damage to pudendalnerves is quite common.Each skeletal muscle, including EAS, has the ability toregenerate to some degree and repair sustained damage. Inresponse to injury and/or muscle damage, so-called satellitecells are activated and become myoblasts—capable of in-tense proliferation. Myoblasts then differentiate and fusetogether to form new muscle fibres and connect withexisting ones, adding new portions of contractile tissue toexisting motoric units [1].Attempts of autotransplantation of myoblasts into dam-aged skeletal muscle were already made in animal models ofmuscular dystrophy, post-infarction myocardial dysfunctionand urethral sphincter insufficiency [2]. The results showedthat the transplanted myoblasts differentiate into musclefibres, connect with host motoric units, increase the amountof contractile elements in the muscle and improve its con-tractile activity. In 2001, Menasche et al. first transplantedautologous myoblasts into the post-infarction myocardialscar in human patients with cardiac failure, with significantimprovements in contractile function and clinical condition[3]. In Poland, the method of treating post-infarction heartfailure was performed for the first time a year later, withsimilar results [4].Basedonthose encouraging results,a pioneerexperimen-tal study was designed in attempt to enhance the function ofexternal anal sphincter using injections of autologousmuscle-derived stem cells. The study is designed as a pro-spective experimental study. It is being conducted by twocooperating research centres—the 3rd Department of Gen-eral Surgery, Jagiellonian University in Cracow and theDepartment of Reproductive Biology and Stem Cells, Insti-tute of Human Genetics, Polish Academy of Sciences inPoznan. We would like to present a case of the representa-tive patient enrolled to our study.A 20-year old male withfaecal incontinenceduetoanoldexternal anal sphincter rupture in a road accident was en-rolled to the study. Sphincter rupture had been repairedsurgically right after the accident (with an end-to-endsphincteroplasty). The patient underwent 6 months of bio-feedback training after the wounds were healed. At the timeof enrolment, he still complained of gas and loose stoolincontinence, daily soiling, with necessity to wear pads.Endoanal ultrasound showed a 8–10-mm scar on the leftcircumference of internal and external sphincter muscle,where anal canal was ruptured during the accident, andsurgically repaired afterwards. Anorectal manometryshowed decreased both mean resting and maximum squeezepressure, with short high pressure zone length. Endoanal

Dynamic versus Adynamic Graciloplasty in Treatment of End-Stage Fecal Incontinence: Is the Implantation of the Pacemaker Really Necessary? 12-Month Follow-Up in a Clinical, Physiological, and Functional Study

Purpose. The aim of the study is to compare functional results of end-stage fecal incontinence treatment with dynamic graciloplasty and adynamic graciloplasty augmented with transanal conditioning of the transposed muscle. Methods. A total of 20 patients were qualified for graciloplasty procedure due to end-stage fecal incontinence. 7 patients underwent dynamic graciloplasty (DGP), whereas 13 patients were treated with adynamic graciloplasty, with transanal stimulation in the postoperative period (AGP). Clinical, functional, and quality of life assessments were performed 3, 6, and 12 months after the procedures. Results. There were no intraoperative or early postoperative complications. The detachment of gracilis muscle tendon was observed in one patient in DGP group and two in AGP group. There was a significant improvement of Fecal Incontinence Quality of Life (FIQL) and Fecal Incontinence Severity Index (FISI) scores in both groups 12 months after procedure. Anorectal manometry showed improvement regarding basal and squeeze pressures in both groups, with significantly better squeeze pressures in AGP group. Conclusions. The functional effects in the DGP and AGP groups were similar. Significantly lower price of the procedure and avoidance of implant-related complication risk suggest the attractiveness of the AGP method augmented by transanal stimulation.

Efficacy of Lift (Ligation of Intersphincteric Fistula Tract) for Complex and Recurrent Anal Fistulas - A Single-Center Experience and A Review of the Literature

UNLABELLED Ligation of intersphincteric fistula tract in treatment of anal fistulas (LIFT) is being said to have satisfactory results in short and long follow up, with low risk of complications. This study was designed to evaluate the results in patients with complex and recurrent fistulas in comparison with simple transsphincteric anal fistulas. The aim of the study was to present a single-center experience in LIFT procedure in treatment of both simple and complex anal fistulas, including recurrent fistulas, in comparison with a review of current literature. MATERIAL AND METHODS A series of 17 patients were qualified to LIFT procedure. 5 patients were treated for simple transsphincteric, 6 for complex fistulas, 6 with fistulas recurrent after fistulotomy. Median age was 47, most of the patients were male (16/17). Mean follow up was 11 months. RESULTS Mean operating time was 55 minutes counting from surgical site disinfection to final dressing of the wound. Of the 17 patients the overall success rate was 53%. As expected, best results were achieved in patients with simple fistulas (80% success rate), then complex (50%), and recurrent fistulas (only 33%). There were no early nor late complications of the surgery. CONCLUSION As expected, in simple transsphincteric fistulas the results were satisfactory, taking into account low complication rate. Complex and recurrent fistulas seem to be risk factors of LIFT failure. The results are consistent with data published by other authors, based on the review of the current literature, and it seems there is still room for improvement, so further research is required.

Low-anterior-resection syndrome. How does neoadjuvant radiotherapy and low resection of the rectum influence the function of anal sphincters in patients with rectal cancer? Preliminary results of a functional assessment study.

UNLABELLED The aim of the study was to assess the influence of neoadjuvant radiotherapy and resection of the rectum on the functional parameters of anal sphincters. MATERIAL AND METHODS 20 patients with rectal cancer, qualified for low anterior rectal resection with neoadjuvant radiotherapy were enrolled in the study group. The study protocol included an anorectal manometry, electromyography and fecal incontinence questionnaire (FISI) before radiotherapy, after radiotherapy, and after the operation. RESULTS Of the 20 patients 12 were included in the final analysis, because 8 patients were re-qualified to abdomino-perineal resection of the rectum after neoadjuvant treatment. There were no significant changes in anal pressures assessed 5 to 8 days after radiotherapy. In 3 cases (25%) pathological changes in RAIR reflex were found in the manometric examination. After low anterior resection mean basal anal pressures were significantly lower, whereas squeeze anal pressures did not change significantly. In 7 patients (58%) the RAIR reflex was pathological or even absent after low anterior resection. Changes in manometric parameters correlated with FISI incontinence assessment after the operation. In electromyographic examination action potentials of motoric units of the external anal sphincter were still present both after radiotherapy, and after operation. CONCLUSIONS Fecal incontinence after low anterior resection of the rectum seems to be caused mostly by changes in autonomic functionality of anal sphincters and lack of compliance of the neorectum, since the influence of neoadjuvant radiotherapy and the operation itself on the somatic innervation of anal sphincters seems to be minimal.

Can surface electromyography improve surgery planning? Electromyographic assessment and intraoperative verification of the nerve bundle entry point location of the gracilis muscle

PURPOSE To verify the precision of surface electromyography (sEMG) in locating the innervation zone of the gracilis muscle, by comparing the location of the IZ estimated by means of sEMG with in vivo location of the nerve bundle entry point in patients before graciloplasty procedure due to fecal incontinence. METHODS Nine patients who qualified for the graciloplasty procedure underwent sEMG on both gracilis muscle before their operations. During surgery the nerve bundle was identified by means of electrical stimulation. The distance between the proximal attachment and the nerve entry point into the muscles body was measured. Both measurements (sEMG and in vivo identification) were compared for each subject. RESULTS On average, the IZ was located 65.5mm from the proximal attachment. The mean difference in location of the innervation zones in each individual was 10±9.7mm, maximal - 30mm, the difference being statistically significant (p=0.017). It was intraoperatively confirmed, that the nerve entered the muscle an average of 62mm from the proximal attachment. The largest difference between the EMG IZ estimation and nerve bundle entry point was 5mm (mean difference 2.8mm, p=0.767). CONCLUSION Preoperative surface electromyography of both gracilis muscles is a safe, precise and reliable method of assessing the location of the innervation zones of the gracilis muscles. The asymmetry of the IZ location in left and right muscles may be important in context of technical aspects of the graciloplasty procedure.

Intraoperative neuromonitoring of hypogastric plexus branches during surgery for rectal cancer – preliminaryreport

AIM The aim of this study was to present our preliminary experience with intraoperative neuromonitoring during rectal resection. MATERIALS AND METHODS We qualified 4 patients (2 women, 2 men; age 42 - 53 years) with rectal cancer for surgery with intraoperative neuromonitoring. In all patients, functional tests of the anorectal area were performed before surgery. Action potentials from the sphincter complex in response to nerve fiber stimulation were recorded with electrodes implanted before surgery. Moreover, we inserted a standard, 18FR Foleys urinary catheter to which a T-tube was connected to allow urine outflow and measurement of pressure changes in the bladder induced by detrusor contractions during stimulation. RESULTS Setting up neuromonitoring prolonged surgery time by 30 to 40 minutes, or even by 60 to 80 minutes in the case of the first two patients. Neuromonitoring itself took additional 20 to 30 minutes during surgery. In all patients, we stimulated branches of the inferior hypogastric plexus in their anatomical position during dissection. In three patients, we evoked responses both from the bladder and the sphincter in all planes of stimulation. In one patient, there was no response from the left side of the bladder, and in the same patient, we observed symptoms of neurogenic bladder. CONCLUSIONS Based on the available literature and our own experience, we state that monitoring of bladder pressure and electromyographic signals from rectal sphincters enables visualization and preservation of autonomic nervous system structures, both sympathetic and parasympathetic. Intraoperative signals seem to be correlated with clinical presentation and functional examinations after surgery. In order to objectify our results, it is necessary to perform functional examinations before and after surgery in a larger group of patients.

Video-Assisted Anal Fistula Treatment: Pros and Cons of This Minimally Invasive Method for Treatment of Perianal Fistulas

Purpose The purpose of this paper is to present results of a single-center, nonrandomized, prospective study of the video-assisted anal fistula treatment (VAAFT). Methods 68 consecutive patients with perianal fistulas were operated on using the VAAFT technique. 30 of the patients had simple fistulas, and 38 had complex fistulas. The mean follow-up time was 31 months. Results The overall healing rate was 54.41% (37 of the 68 patients healed with no recurrence during the follow-up period). The results varied depending on the type of fistula. The success rate for the group with simple fistulas was 73.3%, whereas it was only 39.47% for the group with complex fistulas. Female patients achieved higher healing rates for both simple (81.82% versus 68.42%) and complex fistulas (77.78% versus 27.59%). There were no major complications. Conclusions The results of VAAFT vary greatly depending on the type of fistula. The procedure has some drawbacks due to the rigid construction of the fistuloscope and the diameter of the shaft. The electrocautery of the fistula tract from the inside can be insufficient to close wide tracts. However, low risk of complications permits repetition of the treatment until success is achieved. Careful selection of patients is advised.

Graciloplasty, electrostimulation, electromyography. Clinical implications of electrophysiological phenomena in the neo-sphincter created from the gracilis muscle

UNLABELLED The aim of the study was to compare the electrophysiological phenomena occurring in the gracilis muscle, transposed into the pelvic floor during the graciloplasty procedure, subjected to continuous electrical stimulation by means of implanted stimulator, or regular stimulation by means of an external device, as well as the long-term functional results of the graciloplasty procedure. MATERIAL AND METHODS A total of 27 patients were included in the analysis. The study group consisted of 7 patients after dynamic graciloplasty, 11 patients after graciloplasty followed by transrectal stimulation, 4 patients after graciloplasty with transcutaneous stimulation, and 5 patients after graciloplasty without any stimulation. All patients had a surface electromyographic examination of the transposed gracilis muscle performed, the signal for each patient was compared to the signal acquisited from a non-transposed gracilis in the same patient. In addition, each subject underwent a clinical operation results assessment, as well as an anorectal manometry examination. RESULTS In the electromiographic examination, the mean frequency of motor units action potentials of the gracilis muscle in the thigh was 64 Hz, and in the muscle after transposition and stimulation period mean frequency was 62 Hz. There was no statistically significant difference in the frequency of action potentials before and after treatment in any of the analyzed groups, or between groups with different methods of stimulation (p> 0.05). We found a significant correlation between the clinical outcome of the procedure, and the average amplitude of the EMG signal from the transposed muscle, as well as between the amplitude of the EMG signal and the basal pressure in the anal canal in manometric examination. There were no significant correlations in the remaining manometric parameters. CONCLUSIONS Despite the different methods of postoperative stimulation, including expensive implantable stimulators, there was no difference in the electrical activity between the transposed gracilis muscle, and the gracilis muscle left in situ. There was no signoficant advantage of the dynamic graciloplasty procedure over the graciloplasty with transanal or transcutaneous stimulation.

Mesenchymal Stem Cells in Treatment of Perianal and Rectovaginal Fistulas

Perianal fistulas are still a major challenge in everyday clinical practice. Particularly difficult fistulas, like those in Crohns Disease, often require multiple aggressive surgical interventions, with high risk of sphincter damage and incontinence. Intensive trials have been conducted for over 10 years on the treatment of difficult fistulas with mesenchymal stem cells (MSC). This paper presents a short review of basic mechanisms of mesenchymal stem cells in healing of damaged tissues and results of major clinical trials. MSC in perianal fistulas, regardless of research protocol has a 70% healing rate in recurrent fistulas and in fistulas in Crohns Disease. Further research is needed to precisely define the indications for MSC-based treatment of tissue damage, and particularly perianal and recto-vaginal fistulas.