Piotr Wałęga

Doppler guided haemorrhoidal arterial ligation with recto‐anal‐repair (RAR) for the treatment of advanced haemorrhoidal disease

Objective  A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto‐anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given.

VAAFT: a new minimally invasive method in the diagnostics and treatment of anal fistulas--initial results.

UNLABELLED The aim of the study was to present our own experience in the treatment of anal fistulas by means of VAAFT (Video-Assisted Anal Fistula Treatment). MATERIAL AND METHODS Twenty patients were qualified for the VAAFT procedure. All were subjected to diagnostics. Two patients after the diagnostic stage underwent classical fistula surgery. The remaining 18 patients were subjected to the full procedure (diagnostic fistuloscopy, supply of the internal ostium, and coagulation of the fistula canal). The mean observation period was 10 months. RESULTS In most cases the trans-sphincter fistula was observed during the diagnostic phase, including three with additional fluid compartments. There was one intersphincteric fistula. Considering the 18 patients subjected to the full VAAFT procedure the internal ostium was supplied by means of an advancement flap in 3 cases, while in 11 by means of a mattress suture, including one with additional tissue glue. In 4 cases the internal ostium was tightly covered by mucosa. Surgical complications were not observed during the procedure. During further observation a permanent fistula was observed in 4 (22%) patients, and in two (17%), recurrence of anal fistula. In the remaining 12 patients one observed healing without fistula recurrence. Complications were not observed, including stool and gas control deterioration (based on the FISI scoring). CONCLUSIONS The VAAFT method does not affect sphincter efficiency, no intra- and postoperative complications were observed. As compared to other minimally invasive procedures a comparable recovery rate is observed without the risk of incontinence. It is the only method enabling the intraoperative identification of the internal ostium and fistula canal under visual control. Initial optimistic results require further investigations on a larger group of patients.

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.

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.

Transanal endoscopic microsurgery combined with endoscopic posterior mesorectum resection in the treatment of patients with T1 rectal cancer - 3-year results

Introduction Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 rectal cancer (RC). However, it is associated with an increased rate of local recurrence in comparison with extended resection. In most cases this failure is linked to inappropriate case selection and the presence of clinically non-detectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in a minimally invasive way, which in turn can help in adequate tumor staging. Aim To evaluate the long-term clinical results and influence of combined TEM and EPMR treatment on the anorectal functions. Material and methods Ten consecutive patients with T1 RC were operated on using TEM and EPMR as a two-stage procedure between 2007 and 2009. Results After a median follow-up of 42.6 (range: 36–80) months, none of our patients complained of symptoms of incontinence apart from one female patient with gas incontinence diagnosed preoperatively. There was no statistically significant difference in basal anal pressure, squeeze anal pressure, high pressure zone length or fecal continence assessed using the Fecal Incontinence Severity Index before and in follow-up months after the procedure. Postoperative morbidity consisted of one hematoma formation and one male patient complaining about sexual dysfunction until 6 months postoperatively. There was no evidence of locoregional recurrence. Conclusions Endoscopic posterior mesorectal resection in combination with TEM appears to be safe, feasible and with no impact on the basic anorectal functions in the 3-year follow-up.

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.

Gastrointestinal obstruction in patients previously treated for malignancies

UNLABELLED Bowel obstruction is a common condition in acute surgery. Among the patients, those with a history of cancer consist a particular group. Difficulties in preoperative diagnosis - whether obstruction is benign or malignant and limited treatment options in patients with reoccurrence or dissemination of the cancer are typical for this group. The aim of the study was to analyze causes of bowel obstruction in patients with history of radical treatment due to malignancy. MATERIAL AND METHODS Patients with symptoms of bowel obstruction and history of radical treatment for malignancy who were operated in 2nd and 3rd Department of General Surgery JUCM between 2000 and 2014 were included into the study. The patients were divided into 2 groups based on type of mechanical bowel obstruction (group 1 - adhesions, group 2 - malignant process). RESULTS 128 patients were included into the study - group 1: 67 (52.3%) and group 2: 61 (47.7%). In the second group bowel obstruction was caused by reoccurrence in 25 patients (40.98%) and dissemination in 36 (59.02%). The mean time between onset of the symptoms of bowel obstruction and the end of treatment for the cancer was 3.7 and 4.4 years, respectively in group 1 and 2 (p>0.05). Median time between onset of the symptoms and admission to Emergency Department was significantly longer in patients with malignant bowel obstruction compared to those with adhesions (11.6 ±17.8 days vs 5.1 ± 6.9 days, p=0.01). Considering type of surgery due to bowel obstruction, in first group in most patients (69.2%) bowel resection was not necessary and in the second group creation of jejuno-, ileo- or colostomy was the most common procedure. Morbidity was significantly higher in second group (45.9% vs 28.26%, p<0.05) but there was no difference in mortality (26% vs 24%, p>0.05). In both groups the most common localization of primary malignancy was colon. CONCLUSIONS In analyzed group of patients frequency of bowel obstruction caused by adhesions and malignancy was similar. However, in patients with bowel obstruction caused by malignancy morbidity was significantly higher and duration of symptoms was longer. There was no diagnostic procedure which would allow to differentiate the cause of bowel obstruction preoperatively and the diagnosis was made during the operation.

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.