P. Armendariz

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.

Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer.

Abdominal perineal excision (APE) was originally described with levator ani removal for rectal cancer. An even wider, more aggressive extralevator resection for APE has been proposed. Although some surgeons are performing a very wide ‘extralevator APE (ELAPE)’, there are few data to recommend it routinely. This multicentre study aimed to compare outcomes of APE and ELAPE.

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.

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.

Influence of Rescrubbing Before Laparotomy Closure on Abdominal Wound Infection After Colorectal Cancer Surgery: Results of a Multicenter Randomized Clinical Trial

OBJECTIVE To test the hypothesis that strict asepsis in closing wounds following laparotomy reduces the risk for surgical wound infection in elective colorectal cancer surgery. DESIGN Multicenter randomized clinical trial conducted from June 1, 2009, through June 1, 2010. SETTINGS Colorectal surgery units of 9 Spanish hospitals. PATIENTS A total of 969 patients who underwent elective colorectal cancer surgery were eligible for randomization. In closing the laparotomy wound, the patients were randomized to 2 groups: conventional (n=516) and new operation (n=453). In the conventional group, a new set of instruments was used, surgical staff changed their gloves, and the surgical drapes surrounding the laparotomy were covered by a new set of drapes. The new operation group involved removing all drapes, the surgical staff scrubbed again, and a new set of drapes and instruments was used. MAIN OUTCOME MEASURES Incisional (superficial and deep) surgical site infection 30 days after the operation and risk factors for postoperative wound infections. RESULTS A total of 146 incisional surgical site infections (15.1%) were diagnosed. Of these, 96 (9.9%) were superficial and 50 (5.1%) were deep infections. On an intent-to-treat basis, significant differences were found between both groups (66 [12.8%] in the conventional group vs 80 [17.7%] in the new operation group [P=.04]). CONCLUSION This study does not support the use of rescrubbing to reduce the incidence of incisional surgical site infection. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN19463413

Hemorroidectomía mediante máquina de sutura automática (técnica de Longo). ¿Son reproducibles los resultados de esta técnica?

Resumen Introduccion Recientemente, se ha propuesto el tratamiento de la enfermedad hemorroidal mediante la exeresis y sutura del prolapso mucoso mediante una maquina de autosutura circular, tecnica con la que se han descrito resultados excelentes tanto en terminos de curacion de la enfermedad como de alivio del dolor postoperatorio. El objetivo de este trabajo prospectivo ha sido evaluar la simplicidad del procedimiento, el dolor en el postoperatorio y las complicaciones de esta intervencion. Pacientes y metodo Veinticinco pacientes consecutivos, 19 con hemorroides de grado III y seis de grado IV fueron tratados con la tecnica descrita por Longo, utilizandose el dispositivo PPH (ethicon endo-surgery). En todos los casos se indico la misma pauta analgesica y fueron dados de alta 2 dias despues de la intervencion. Para evaluar el dolor se utilizo una escala analogica visual, con un rango de 0-10 puntos. Al alta se le entregaba al paciente un diario donde debia anotar cada dia la intensidad del dolor, con la misma escala empleada durante la estancia hospitalaria, y el consumo de analgesicos. El tiempo operatorio se midio mediante un cronometro. Se recogieron las complicaciones postoperatorias. Todos los pacientes fueron visitados en la consulta a las 6 semanas de la intervencion, solicitandoles una valoracion de su satisfaccion con la operacion mediante una escala de 0 a 10 puntos. Resultados El tiempo medio del procedimiento fue 12,4 ± 4,20 min (rango, 6,2-25,3). Tres pacientes presentaron complicaciones despues del alta. Ninguno requirio ingreso ni tratamiento quirurgico. La intensidad del dolor postoperatorio fue de 5,2 ± 1,9 puntos (rango, 1-10) el primer dia y 3,1 ± 1,7 (rango, 0-6) el segundo. Todos los pacientes excepto uno requirieron quetorolaco. En 3 casos fue necesario emplear meperidina. La intensidad media mas alta del dolor despues del alta fue 4,6 ± 1,8 puntos (rango, 1-8). La media de dias que los pacientes tomaron analgesicos en su domicilio fue 9,4 ± 6,3. Ningun paciente requirio mas de 3 dosis de quetorolaco. A las 6 semanas el 92% de los pacientes se mostro muy satisfecho con la intervencion. Conclusion En conclusion, la intervencion de Longo es una tecnica sencilla y rapida, con una tasa de complicaciones baja. Sin embargo, el dolor postoperatorio no ha sido tan escaso ni tan infrecuente como cabria esperar de la mayoria de las publicaciones previas.