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Pelvic Prolapse in Coloproctology


Stapled haemorrhoidopexy for haemorrhoids in combination with lateral internal sphincterotomy for fissure-in-ano.
Kanellos I, Angelopoulos S, Zacharakis E, Kanellos D, Pramateftakis MG, Blouhos K, Betsis D
Eur Surg Res. 2005 Sep-Oct;37(5):317-20.

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient's degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures.

[Rectal prolapse in adults - causes, diagnostic, treatment.]
Korenkov M, Junginger T
Zentralbl Chir. 2005 Dec;130(6):544-9.

Despite progress in modern surgery, the choice of the surgical procedure of rectal prolapse is regarded with controversy. Selection criteria between the abdominal or perineal approach or between rectopexy and resection rectopexy are not yet proven. This article gives a review of the literature about rectal prolapse and an analysis of the outcome of posterior rectopexy and resection rectopexy - partly conventionally and partly laparoscopically - in 25 patients with rectal prolapse III degrees and IV degrees . All except for one patient were examined during a mean follow-up of 5.5 (3.1) years for the rectopexy group and 2.1 (0.7) years for the resection rectopexy group. Recurrence occurred in one patient in each group respectively. There was no significant difference concerning the continence function (p = 0.32) and constipation (p = 0.36) between both groups. No mesh-related complications such as infection, fistula or rectum stenosis were observed. According to the review of the literature and our data, we believe that the choice of the operative procedure for rectal prolapse should be based on individual criteria. Fit patients should be offered laparoscopic procedures such as resection rectopexy and rectopexy without colonic resection.

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study.
Kariv Y, Delaney CP, Casillas S, Hammel J, Nocero J, Bast J, Brady K, Fazio VW, Senagore AJ
Surg Endosc. 2005 Dec 21;.

BACKGROUND: Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited. METHODS: Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey. RESULTS: A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17). CONCLUSIONS: The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Open vs. closed hemorrhoidectomy.
Khubchandani I
Tech Coloproctol. 2005 Dec;9(3):256; discussion 256.

Mucosal prolapse in the pathogenesis of Peutz-Jeghers polyposis.
Jansen M, de Leng WW, Baas AF, Myoshi H, Mathus-Vliegen L, Taketo MM, Clevers H, Giardiello FM, Offerhaus GJ
Gut. 2006 Jan;55(1):1-5.

Germline mutations in LKB1 cause the rare cancer prone disorder Peutz-Jeghers syndrome (PJS). Gastrointestinal hamartomatous polyps constitute the major phenotypic trait in PJS. Hamartomatous polyps arising in PJS patients are generally considered to lack premalignant potential although rare neoplastic changes in these polyps and an increased gastrointestinal cancer risk in PJS are well documented. These conflicting observations are resolved in the current hypothesis by providing a unifying explanation for these contrasting features of PJS polyposis. We postulate that a genetic predisposition to epithelial prolapse underlies the formation of the polyps associated with PJS. Conventional sporadic adenomas arising in PJS patients will similarly show mucosal prolapse and carry the associated histological features.

Jaundice as a presentation of phenol induced hepatotoxocity following injection sclerotherapy for haemorrhoids.
Suppiah A, Perry EP
Surgeon. 2005 Feb;3(1):43-4.

A 43-year-old man was admitted with jaundice six days following phenol injection sclerotherapy for haemorrhoids. He was diagnosed with a phenol-induced hepatitis. Although he remained well, liver function tests only returned to normal after six months. Systemic absorption of phenol has been reported with ingestion, upper airway and excessive cutaneous exposure but not as a complication of haemorrhoidal injection sclerotherapy. Hepatic involvement is also rare and usually the result of ongoing sepsis. We report the unique case of a patient presenting with jaundice secondary to chemical hepatitis, following systemic absorption of phenol at injection sclerotherapy. This case highlights the importance of clinical awareness of not only the infective complications of injection sclerotherapy but also the potential for phenol to be absorbed systemically with severe consequences. A brief overview of symptoms of phenol toxicity is included.

Daflon for haemorrhoids: a prospective, multi-centre observational study.
Meshikhes AW
Surgeon. 2004 Dec;2(6):335-8, 361.

BACKGROUND: Daflon, a phlebotropic agent, is of proven efficacy in the treatment of various venous disorders. Although it has been tried in the treatment of haemorrhoids, its efficacy in alleviating various haemorrhoidal symptoms has not been assessed properly. The aim of this study was to confirm the efficacy of Daflon in the treatment of haemorrhoidal symptoms. METHODS: Two hundred and sixty eight patients presenting with haemorrhoidal symptoms were recruited. This was a multicentre non-randomised observational study with no placebo arm. After establishing the extent of their symptoms and determining the position, size and degree of haemorrhoids by proctoscopy, all patients were started on Daflon, four tablets per day, in two divided doses for four weeks. Patients were seen weekly during the study period and carefully questioned as regard to symptoms, and a proctoscopy was carried out. RESULTS: There was a statistically significant improvement (p<0.001) in all haemorrhoidal symptoms (pain, heaviness, bleeding, pruritus and anal discharge) and in the proctoscopic appearance of the 'piles,' comparing baseline visit findings with the last visit four weeks after treatment with Daflon. CONCLUSIONS: Daflon has been shown to be effective in alleviating (variable degree) haemorrhoidal symptoms and improving the proctoscopic appearance of haemorrhoids. Therefore, it should be considered initially for patients presenting with haemorrhoidal symptoms. However, prospective randomised trials and longer follow-up are needed to confirm the findings of this study and delineate more precisely the role of Daflon in the management of haemorrhoidal disease

Experience of 3711 stapled haemorrhoidectomy operations.
Ng KH, Ho KS, Ooi BS, Tang CL, Eu KW
Br J Surg 2005 Dec 1;.

BACKGROUND: Stapled haemorrhoidectomy has been routinely performed in the Department of Colorectal Surgery, Singapore General Hospital since 1999. METHODS: A retrospective review was undertaken of all patients who underwent stapled haemorrhoidectomy between October 1999 and May 2004. The outcomes studied were patient profiles, priority of operation, indications for surgery, length of operation, postoperative complications and recurrences. RESULTS: A total of 3711 patients (51.1 per cent women) had the surgery. The median patient age was 50 (range 18-88) years. The main indications were bleeding (80.7 per cent), haemorrhoidal prolapse (59.6 per cent) and thrombosis (3.9 per cent). The median duration of operation was 15 (range 5-45) min. Minor complications occurred in 12.3 per cent of patients: acute retention of urine (4.9 per cent), bleeding (4.3 per cent), significant postoperative pain requiring admission (1.6 per cent), anorectal stricture (1.4 per cent), perianal haematoma (0.05 per cent) and significant residual skin tags (0.05 per cent). One patient developed a perianal abscess after stapled haemorrhoidectomy. Anastomotic dehiscence occurred in three patients (0.08 per cent). Twelve (0.3 per cent) patients had a recurrence at a median of 16 (range 5-45) months. CONCLUSION: Considerable experience of stapled haemorrhoidectomy confirms it as a safe and effective procedure.

Anal Fissure and Minor Anorectal Sepsis After Stapled Hemorrhoidectomy.
Dis Colon Rectum 2005 Nov 16;.

Stapled Hemorrhoidopexy: An Alternative Technique for the Treatment of Bleeding Anorectal Varices. Report of a Case.
Parvaiz A, Azeem S, Singh RK, Lamparelli M
Dis Colon Rectum 2005 Dec 8;.

Stapled Hemorrhoidopexy: A New Device and Method of Performance Without Using A Pursestring Suture.
Hoffman GH
Dis Colon Rectum 2005 Nov 16;.

PURPOSE: This study was designed to develop a more reliable device and technique that will allow for the safer and reproducibly consistent performance of a stapled hemorrhoidopexy without using a pursestring suture. This device and technique must allow the surgeon to be able to control the volume of tissue drawn into the stapler center chamber during the performance of the procedure. METHODS: A porcine model was used to evaluate and perfect a mucosal impalement device and technique for use during the performance of a stapled hemorrhoidopexy. A specially manufactured washer with spikes on one side was fitted onto the center shaft of a PROXIMATE(R) PPH01 Hemorrhoidal Circular Stapler and was used in each of nine animals. A pursestring suture was not needed and was not used in any of the procedures. RESULTS: After performing the stapled hemorrhoidopexy, a mucosal donut was obtained from each animal. On gross inspection, each donut was of similar size, height, and volume compared with that of a human stapled hemorrhoidopexy donut. Each was completely circumferential (except for the final specimen, which was purposely incomplete after having performed a single quadrant resection). The performance of each procedure required approximately one minute. CONCLUSIONS: A procedure and device have been developed that allow for the rapid, safe, and reliable performance of a sutureless stapled hemorrhoidopexy by using a new mucosal impalement device and technique in the porcine model. It was used successfully in the porcine model under simulated diverse clinical circumstances. The procedure is easy to teach and learn and has potential applicability for use in humans.

The Authors Reply.
Brusciano L, Ayabaca SM, Pescatori M, Ravo B, Accarpio GM, Dodi G, Cavallari F, Annibali R
Dis Colon Rectum 2005 Nov 16;.

A modified anoscope to facilitate the purse-string suture for stapled hemorrhoidopexy.
Bozdag AD
Tech Coloproctol 2005 Nov 21;.

Stapled hemorrhoidopexy is an alternative method to conventional surgical procedures for third-degree hemorrhoids. It has many advantages such as less pain, faster recovery and earlier return to work. Nevertheless, many reports mentioned the persistence of postoperative pain, hemorrhage, recurrence, sphincter injury, and pelvic sepsis. The complications mostly arose during the purse-string phase of the procedure. The internal hemorrhoids and loose rectal mucosa can fill the inside of the anoscope, obstruct the operation field and restrict the maneuverability of the needle holder. To overcome this difficulty, a specially designed anoscope may be used. The purse-string anoscope of the PPH 01 kit (Ethicon Endo-Surgery, Cincinnati, USA) was modified to overcome the obstruction of the staple line by internal hemorrhoids and rectal mucosal prolapse. Stapled mucosectomy with this modified anoscope was performed in 9 patients. The surgical procedure lasted approximately 25 min and the patients healed uneventfully, even though 4 of them had been operated on by surgeons in their first attempts with stapled hemorrhoidopexy. By using a modified anoscope, ideal purse-string suturing may become easier, intraoperative time may be shortened, and the learning curve may be reduced.

New devices for stapled rectal mucosectomy: a multicenter experience.
Pinheiro Regadas FS, Murad Regadas SM, Rodrigues LV, Misici R, Tramujas I, Barreto JB, Alvaro Lins M, Roberto Silva F, Regadas Filho FS
Tech Coloproctol 2005 Nov 21;.

Stapled mucosectomy is widely performed, but in patients with deep gluteal cleft and small distance between the ischial tuberosities, it is difficult to insert the PPH dilator. We report the results achieved with a new device, the EEA 34-mm circular stapler (Auto-Suture, New Haven, USA). Eighty-five patients (45 men) were submitted to stapled mucosectomy for treatment of third- (n=70) or fourth-degree (n=10) hemorrhoids or mucosal prolapse (n=5) by surgeons at four different centers. The patients' mean age was 53.9 years (range, 45-70 years). ASA Kit (Advanced Surgical Anoscope, Tecplast Company, Fortaleza, Brazil) consists of four devices: a circular anal dilator (CAD) with anterior and posterior wings, an accessory device for insertion of CAD into the anal canal, a circular surgical anoscope (CSA) with proximal and distal openings for placing the rectal mucosal purse-string sutures, and a CSA insertion device. The middle part of the CSA is fully circular in order to avoid that the piles or the prolapsed mucosa fall into the anoscope. The mean excised mucosal band width was 4.7 cm. The mean operative time was 16 min (range, 12-25 min). Bleeding from the stapled suture was observed in 10 patients (11.7%). There were 5 postoperative complications (5.9%): 3 perianal hematomas and 2 stapled suture strictures. Anopexy was considered excellent by the surgeons in 50 patients (58.8%), good in 25 (29.4%) and poor in 10 (11.7%). At a mean follow-up of 12 months, proctoscopy demonstrated residual asymptomatic small internal prolapses in 15 patients (17.6%). Full pile prolapses recurred in 2 (2.3%) and required diathermy excision. ASA Kit made stapled mucosectomy easier to perform, but it's necessary to improve the circular staplers to adequately treat all sizes of mucosal and hemorrhoidal prolapses in order to reduce the recurrence rates.

Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience.
Rosa G, Lolli P, Piccinelli D, Vicenzi L, Ballarin A, Bonomo S, Mazzola F
Tech Coloproctol 2005 Nov 21;.

BACKGROUND: Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks.METHODS: A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia.RESULTS: Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture.CONCLUSIONS: Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

Solitary rectal ulcer syndrome: endoscopic spectrum and review of the literature.
Sharara AI, Azar C, Amr SS, Haddad M, Eloubeidi MA
Gastrointest Endosc 2005 Nov;62(5):755-762.

Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy.
Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJ, Loudon MA
Br J Surg 2005 Oct 27;.

BACKGROUND AND METHOD: This review compares the two most popular treatments for haemorrhoids, namely rubber band ligation (RBL) and excisional haemorrhoidectomy. Randomized trials were identified from the major electronic databases. Symptom control, retreatment, postoperative pain, complications, time off work and patient satisfaction were assessed. Relative risk (RR) and weighted mean difference with 95 per cent confidence interval (c.i.) were estimated using a random-effects model for dichotomous and continuous outcomes respectively. RESULTS: Three trials met the inclusion criteria and all were of poor methodological quality. Complete remission of haemorrhoidal symptoms was better after haemorrhoidectomy (RR 1.68 (95 per cent c.i 1.00 to 2.83)). There was significant heterogeneity between the studies (I(2) = 90.5 per cent; P < 0.001). Fewer patients required retreatment after haemorrhoidectomy (RR 0.20 (95 per cent c.i 0.09 to 0.40)), but anal stenosis, postoperative haemorrhage and incontinence to flatus were more common with this operation. CONCLUSIONS: Haemorrhoidectomy produced better long-term symptom control in patients with grade III haemorrhoids, but was associated with more postoperative complications than RBL.

Stapled Hemorrhoidectomy Under Local Anesthesia: Tips and Tricks.
Delikoukos S, Zacharoulis D, Hatzitheofilou C
Dis Colon Rectum 2005 Oct 3;.

Stapled hemorrhoidectomy-a new, evolving technique-is considered to be safe and painless. General and spinal anesthesia are the "gold standard" anesthetic techniques for the procedure. The stapled hemorrhoidectomy under local anesthesia is described. Emphasis is given in few tips and tricks for safe and successful application of the local anesthesia.

Doppler-Guided Hemorrhoidal Artery Ligation: An Alternative to Hemorrhoidectomy.
Felice G, Privitera A, Ellul E, Klaumann M
Dis Colon Rectum 2005 Sep 30;.

PURPOSE: Postoperative pain is the main adverse effect of formal hemorrhoidectomy. A new technique based on Doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy. The authors report a preliminary experience with this procedure. METHODS: The Doppler-guided hemorrhoidal artery ligation technique uses a special proctoscope bearing a Doppler transducer that allows identification and suture ligation of the hemorrhoidal arteries. Sixty-eight consecutive patients (mean age, 48 years; range, 21-74 years) with Grade 3 hemorrhoids were treated. RESULTS: Intraoperative discomfort was measured by a visual analog scale (1-10) and resulted in a mean score of 2.3 (range, 1.3-2.8). Only 38 percent of patients required postoperative analgesia. Patients were examined at 1 week, 1 month, and 3 months and every 6 months thereafter. The mean follow-up was 11 (range, 3-18) months. Bleeding resolved in 91 percent of patients, pain in 73 percent, and prolapse in 94 percent. Complications were recorded in five patients and included persistent pain for more than two days in two patients (3 percent), swelling and thrombosis of one of the hemorrhoids in two patients (3 percent), and a secondary hemorrhage in one patient (1.5 percent). CONCLUSION: Doppler-guided ligation of the hemorrhoidal artery is a safe and effective alternative to hemorrhoidectomy and is associated with minimal discomfort and low risk of complications.

Prospective study of the effect of rectopexy on colonic motility in patients with rectal prolapse.
Brown AJ, Nicol L, Anderson JH, McKee RF, Finlay IG
Br J Surg 2005 Sep 26;.

BACKGROUND: Patients with rectal prolapse have abnormal hindgut motility. This study examined the effect of rectal prolapse surgery on colonic motility. METHODS: Twelve patients undergoing sutured rectopexy were studied before and 6 months after surgery by colonic manometry, colonic transit study and clinical assessment of bowel function. The results were compared with those from seven control subjects. RESULTS: Before surgery colonic pressure was greater in patients than controls (P < 0.050). Controls responded to a meal stimulus by increasing colonic pressure; this increase was absent in patients. After rectopexy, colonic pressure reduced towards control values and patients' colonic pressure response to a meal returned. High-amplitude propagated contractions (HAPCs) were seen in all controls but in only three patients before and two patients after surgery. Three patients had prolonged colonic transit before and eight after rectopexy. CONCLUSION: Patients with rectal prolapse have abnormal colonic motility associated with reduced HAPC activity. Rectopexy reduces colonic pressure but fails to restore HAPCs, reduce constipation or improve colonic transit. These observations help explain the pathophysiology of constipation associated with rectal prolapse.

Hemorrhoidal Ablation and Fixation: An Alternative Procedure for Prolapsing Hemorrhoids.
Gupta PJ
Digestion 2005 Sep 19;72(2-3):

Background: Many new techniques have been evolved to curb the problem of post-operative pain after hemorrhoidectomy. Stapler hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation are the two methods gaining popularity amongst proctologists. The author proposes another technique called radiofrequency ablation and fixation of hemorrhoids to add to this list. Patients and Methods: The surgical technique and clinical follow-up of 410 patients operated by this technique are presented. An Ellman radiofrequency generator was used for hemorrhoidal ablation at the output power intensity of 80. Post-defecation pain and pain at rest were assessed using a visual analogue scale. Patient satisfaction score was calculated at the mean follow-up of 60 months (range 48-72). The results in terms of mean hospital stay, post-operative pain, post-operative complications, and period of incapacity for work were compared with the published data of results of stapled hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation. Results: Pain score at first evacuation was 6. The post-defecation pain score in the first week was 4 (range 3-6) and it was 3 (range 2-5) in the second week. The mean pain score at rest in the first week was 2 (range 1-4) and 1 (range 0-2) in the second post-operative week. In the long-term follow-up at a mean of 60 months, this procedure was found in most of the cases to control prolapse, discharge, and bleeding, with no stenosis or incontinence. The recurrence rate was less than 2%. The patient satisfaction score was high. Conclusion: The results of this technique of radiofrequency ablation and fixation of hemorrhoids hold positive promises in terms of less post-operative pain, early discharge from the hospital and faster return to work. The results are comparable to stapled hemorrhoidopexy and are better than Doppler-guided hemorrhoidal artery ligation in terms of effectiveness and symptomatic relief on a long-term basis.


Medical vs. Surgical Management of Thrombosed External Hemorrhoids.

Hall NR
Dis Colon Rectum 2005 Aug 3;.

Anorectal Physiology in Solitary Ulcer Syndrome: A Case-Matched Series.
Morio O, Meurette G, Desfourneaux V, D'Halluin PN, Bretagne JF, Siproudhis L
Dis Colon Rectum 2005 Aug 16;.

PURPOSE: Solitary ulcer syndrome is a rare condition characterized by inflammation and chronic ulcer of the rectal wall in patients suffering from outlet constipation. Despite similar surgical options (rectopexy, anterior resection), solitary ulcer syndrome may differ from overt rectal prolapse with regard to symptoms and pathogenesis. The present work analyzed differences between these conditions in a case-control physiology study. METHODS: From 1997 to 2002, 931 consecutive subjects were investigated in a single physiology unit for anorectal functional disorders. Standardized questionnaires, anorectal physiology, and evacuation proctography were included in a prospective database. Diagnosis of solitary ulcer syndrome was based on both symptoms and anatomic features in 25 subjects with no overt rectal prolapse (21 females and 4 males; mean age, 37.2 +/- 15.7 years) and no past history of anorectal surgery. They were compared with age-matched and gender-matched subjects: 25 with outlet constipation (also matched on degree of internal procidentia), 25 with overt rectal prolapse without any mucosal change, and 14 with overt rectal prolapse and mucosal changes. RESULTS: Subjects with solitary ulcer syndrome reported symptomatic levels (digitations, pain, incontinence) similar to those of patients with outlet constipation, but they had significantly more constipation and less incontinence than patients with overt rectal prolapse. Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3, and 1, respectively ; P < 0.01) and a paradoxical puborectalis contraction (15 vs. 9, 1, and 1, respectively; P < 0.05). With respect to evacuating proctography, complete rectal emptying was achieved less frequently in this group (5 vs. 12, 23, and 10, respectively; P < 0.05). Compared with patients with overt rectal prolapse, mean resting and squeezing anal pressures were significantly higher in both groups of subjects with solitary ulcer syndrome and with outlet constipation. Prevalence and levels of anatomic disorders (perineal descent, rectocele) did not differ among the four groups except for rectal prolapse grade and prevalence of enterocele (higher in overt rectal prolapse group). Interestingly, and despite matched controls for degree of intussusception, individuals with solitary ulcer syndrome had circular internal procidentia more often compared with those suffering from outlet constipation without mucosal lesions (15 vs. 8, P < 0.05). CONCLUSION: This case-controlled study quantifies functional anal disorders in patients suffering from solitary ulcer syndrome. Despite no proven etiologic factor, sphincter-obstructed defecation and circular internal procidentia both may play an important part in the pathogenesis and an exclusive surgical approach may not be appropriate in this context.

Solitary rectal ulcer syndrome An endoscopic and histological presentation and literature review.
Chiang JM, Changchien CR, Chen JR
Int J Colorectal Dis 2005 Aug 17;:1-9.

BACKGROUND: Although the clinicopathologic features of solitary rectal ulcer syndrome (SRUS) are well documented, the heterogeneous endoscopic appearance of lesions that the syndrome produces and its rare incidence may make for clinical confusion. METHODS: Together with a literature review, we describe the variety of lesions experienced in our hospital with a series of endoscopic and histological illustrations and emphasize the diagnostic dilemma both clinically and histologically. CONCLUSIONS: With comparison of different macroscopic presentations of SRUS, more correct diagnoses will be achieved and more successful treatments will be reported.

Delorme's procedure for rectal prolapse in a child refractory to conservative treatment and rectal suspension.
Joshi AA, Milanovic DM
Int J Colorectal Dis 2005 Aug 11;:1-2.

Closed rectopexy with transanal resection for complete rectal prolapse in adults.
Lasheen AE, Khalifa S, El Askry SM, Elzeftawy AA
Gastrointest Surg 2005 Sep-Oct;9(7):980-4.
Many techniques have been described for repair of complete rectal prolapse in adults. The results of abdominal approaches are superior to those of perineal approaches, but they carry the risks of major abdominal surgery. Twenty-seven patients (15 females and 12 males) were included in this study, with a mean age of 46 years. Nine of these patients had fecal incontinence. The operation can be performed under spinal or general anesthesia. The operation involves transanal resection of the redundant part of the rectum followed by rectopexy through small postanal incisions. The mean follow-up period was 24 months. One patient developed infection in one stab incision 6 months after the operation. Two patients had hematoma formation, which were managed conservatively. During the 2-year period of follow-up, no recurrence was observed in any of our patients. Fecal incontinence improved in the nine incontinent patients. The technique is simple, easy, and less invasive with good results and less morbidity and is not associated with serious complications.

The treatment of rectal prolapse in children with phenol in almond oil injection.
Angerpointner TA
J Pediatr Surg 2005 Jul;40(7):1217.

The treatment of rectal prolapse in children is controversial. The authors report their results of injection sclerotherapy in children using phenol in almond oil (PAO) and discuss the occurrence of complications after injection of PAO. Nine children with rectal prolapse, aged from 2 to 14 years were treated by PAO injection sclerotherapy. The outcome of PAO injection regarding anorectal function was assessed by anorectal manometry. All nine patients were cured after one to three injections without any complications. Manometric parameters were normal after injection therapy. Two out of 4 children with constipation prior to injection therapy had no longer constipation thereafter. It is thus concluded that PAO injection therapy is a simple and safe procedure and should be considered as first method of treatment in anorectal prolapse in children.

Stapled hemorrhoidectomy.
Nunoo-Mensah JW, Kaiser AM
Am J Surg 2005 Jul;190(1):127-30.

Stapled hemorrhoidectomy has rapidly evolved and become the procedure of choice for primarily internal hemorrhoids. Even though the technique is relatively straightforward, only strict adherence to its principles will avoid serious complications and preserve the previously described benefits of this method. Recurring questions during teaching courses as well as several pitfalls that might result in suboptimal outcomes have prompted us to highlight some important details and modifications of the surgical technique.

Stapled Hemorrhoidopexy Versus Milligan-Morgan Hemorrhoidectomy: A Prospective, Randomized, Multicenter Trial With 2-Year Postoperative Follow Up.
Gravie JF, Lehur PA, Huten N, Papillon M, Fantoli M, Descottes B, Pessaux P, Arnaud JP
Ann Surg 2005 Jul;242(1):29-35.

PURPOSE: The purpose of this study was to compare the outcome of stapled hemorrhoidopexy (SH group) performed using a circular stapler with that of the Milligan-Morgan technique (MM group). The goals of the study were to evaluate the efficacy and reproducibility of stapled hemorrhoidopexy and define its place among conventional techniques. METHODS: A series of 134 patients were included at 7 hospital centers. They were randomized according to a single-masked design and stratified by center (with balancing every 4 patients). Patients were clinically evaluated preoperatively and at 6 weeks, 1 year, and a minimum of 2 years after treatment. Patients completed a questionnaire before and 1 year after surgery to evaluate symptoms, function, and overall satisfaction. RESULTS: The mean follow-up period was 2.21 years +/- 0.26 (1.89-3.07). Nine patients (7%) could not be monitored at 1 or 2 years, but 4 of these 9 nevertheless filled in the 1-year questionnaire. The patients in the SH group experienced less postoperative pain/discomfort as scored by pain during bowel movement (P < 0.001), total analgesic requirement over the first 3 days (according to the World Health Organization [WHO] class II analgesics [P = 0.002]; class III [P = 0.066]), and per-patient consumption frequency of class III analgesics (P = 0.089). A clear difference in morphine requirement became evident after 24 hours (P = 0.010). Hospital stay was significantly shorter in the SH group (SH 2.2 +/- 1.2 [0; 5.0] versus MM 3.1 +/- 1.7 [1; 8.0] P < 0.001). At 1 year, no differences in the resolution of symptoms were observed between the 2 groups, and over 2 years, the overall incidence of complications was the same, specifically fecaloma (P = 0.003) in the MM group and external hemorrhoidal thrombosis (P = 0.006) in the SH group. Impaired sphincter function was observed at 1 year with no significant difference between the groups for urgency (12%), continence problems (10%), or tenesmus (3%). No patient needed a second procedure for recurrence within 2 years, although partial residual prolapse was detected in 4 SH patients (7.5%) versus 1 MM patient (1.8%) (P = 0.194). CONCLUSION: Stapled hemorrhoidopexy causes significantly less postoperative pain. The technique is reproducible and can achieve comparable outcomes as those of the MM technique as long as the well-described steps of the technique are followed. Like with conventional surgery, anorectal dysfunction can occur after stapled hemorrhoidopexy in some patients. Its effectiveness in relieving symptoms is equivalent to conventional surgery, and the number of hemorrhoidal prolapse recurrences at 2 years is not significantly different. Hemorroidopexy is applicable for treating reducible hemorrhoidal prolapse.

The safety and efficacy of stapled hemorrhoidectomy in the treatment of hemorrhoids: a systematic review and meta-analysis of ten randomized control trials.
Lan P, Wu X, Zhou X, Wang J, Zhang L
Int J Colorectal Dis 2005 Jun 22;.

AIMS: The objective of this study was to compare the safety and efficacy outcomes of stapled hemorrhoidectomy (PPH) with Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of severe hemorrhoids. METHODS: A meta-analysis pooled the effects of the safety and efficacy outcomes on PPH, and MMH in ten randomized control trials was presented using a fixed effects model or a random effects model (via RevMan Version 4.2). RESULTS: There was reasonably clear evidence in favor of PPH for operating time, length of hospital stay, pain, anal discharge, and patient satisfaction. However, skin tags and prolapse occurred at higher rates in the PPH group. PPH was not more superior than MMH as to postoperative bleeding, urinary retention, difficulty in defecating, anal fissure and stenosis, sphincter damage, resumption of normal activities, incontinence, pruritus, anal resting and squeeze pressures, and analgesia. CONCLUSIONS: PPH may be at least as safe as MMH. However, the efficacy of PPH compared with MMH could not be determined absolutely. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

Successful laparoscopic repair of spontaneous rectosigmoid rupture with an acute transanal small bowel evisceration.
Antony MT, Memon MA
Surg Laparosc Endosc Percutan Tech 2005 Jun;15(3):172-3.

This report describes the first successful laparoscopic approach for transanal small bowel evisceration secondary to spontaneous rectal rupture, indeed a very rare event. A brief description of our technique and the pathophysiologic features of this condition are given.

Rectal intussusception: a study of rectal biomechanics and visceroperception.
Dvorkin LS, Gladman MA, Scott SM, Williams NS, Lunniss PJ.
Am J Gastroenterol 2005 Jul;100(7):1578-85.

OBJECTIVES: Rectal intussusception (RI) is a significant cause of morbidity amongst those with a rectal evacuatory disorder. The pathophysiology is unknown, but may involve abnormal biomechanics of the rectal wall similar to that previously demonstrated in patients with overt rectal prolapse (RP). Using an electromechanical barostat, this study aimed to investigate the biomechanics and visceroperception of the rectal wall in patients with RI. METHODS: Twenty consecutive patients (12 females, median age 46 yr (range 24-66)) with symptomatic, full-thickness RI were studied. Patients underwent assessment of rectal compliance, visceroperception, adaptive response to isobaric distension at urge threshold, and assessment of the postprandial response. Results were compared with those obtained in 28 asymptomatic volunteers, 10 with RI (6 females, median age 29 yr (range 21-36)) and 18 (9 females, median age 33 yr (range 21-62)) without. RESULTS: In the absence of the clinical finding of solitary rectal ulcer syndrome (SRUS), patients with symptomatic RI have normal rectal wall biomechanics, as do asymptomatic volunteers with RI (p < 0.05). Patients with the clinical finding of SRUS had reduced compliance and adaptation. In all three groups, there was a linear relationship between rectal pressure and visceroperception. The postprandial contractile response was similar between groups. CONCLUSIONS: Patients with RI have normal rectal wall biomechanics. This is in contrast to patients with RP, and suggests that while they may represent different stages of the same disease process, they are physiologically distinct. In patients with RI and SRUS, rectal wall inflammation and fibrosis, perhaps arising secondary to the intussusception, may explain the physiological changes observed. (Am J Gastroenterol 2005;100:1-8).

Emergency stapled haemorrhoidectomy for haemorrhoidal crisis.
Kang JC, Chung MH, Chao PC, Lee CC, Hsiao CW, Jao SW
Br J Surg 2005 Jul 4;.

Laparoscopic Resection Rectopexy for Rectal Prolapse.
Kessler H, Hohenberger W. Dis Colon Rectum 2005 Jun 27;.

INTRODUCTION: The laparoscopic approach in suture rectopexy with sigmoid resection is appealing as surgery is mainly confined to the pelvis. METHODS: The procedure is performed in modified lithotomy position using five trocars. In the case reported, the inferior mesenteric artery is divided distally to the left colic artery branch. The sigmoid colon is mobilized medially and may be mobilized laterally up to the descending colon, depending on the extent of resection. The splenic flexure remains in place. The rectum is mobilized from the presacral fascia down to the pelvic floor, sparing the hypogastric nerves. The rectum is transected in its upper third and the colonic stump pulled outside after enlarging the left lower abdominal incision to a length of 5 cm. The colorectal anastomosis is established intracorporeally in a double-stapling technique. Three 2-0 braided nonabsorbable sutures are placed to attach the right lateral stalks of the rectum to the presacral fascia. Proctoscopic examination has to ensure that there is no luminal compromise or air leakage. RESULTS: The videotape reports about a 37-year-old male patient with a rectal prolapse of 8 cm in length. First symptoms had occurred in childhood. He reported about temporary constipation and repeated rectal bleeding. During surgery, an elongated sigmoid was found. Laparoscopic sigmoid resection and suture rectopexy were carried out. There were no intraoperative or postoperative complications. The patient was discharged from the hospital on the sixth postoperative day. CONCLUSION: Laparoscopic resection rectopexy is safely feasible as a minimally-invasive treatment option for rectal prolapse.

The Authors Reply.
Boccasanta P, Venturi M, Stuto A, Bottini C, Caviglia A, Mascagni D, Sofo L, Carriero A, Mauri R, Landolfi V
Dis Colon Rectum 2005 Jun 24;.

Management of Rectal Prolapse in Children.
Antao B, Bradley V, Roberts JP, Shawis R.
Dis Colon Rectum 2005 Jun 16;.

PURPOSE: Rectal prolapse in children is not uncommon and usually is a self-limiting condition in infancy. Most cases respond to conservative management; however, surgery is occasionally required in cases that are intractable to conservative treatment. This study was designed to analyze the outcomes of rectal prolapse in children and to propose a pathway for the management of these cases in children. METHODS: A retrospective analysis of all cases of rectal prolapse referred to our surgical unit during a period of five years was performed. End point was recurrence of prolapse requiring manual reduction under sedation or an anesthetic. Results are presented as median (range) and statistical analysis was performed using chi-squared test; P < 0.05 was considered significant. RESULTS: A total of 49 children (25 males) presented with symptoms of rectal prolapse at a median age of 2.6 years (range, 4 months -10.6 years). All children received an initial period of conservative treatment with watchful expectancy and/or laxatives. Twenty-five patients were managed conservatively without any additional procedures (Group A), and 24 patients had one or more interventions, such as injection sclerotherapy, Thiersch procedure, anal stretch, banding of prolapse, and rectopexy (Group B). Management of rectal prolapse was successful with no recurrences in 24 patients (96 percent) in Group A vs. 15 patients (63 percent) in Group B at a median follow-up period of 14 (range, 2-96) months. An underlying condition was found in 84 percent of patients in Group A vs. 54 percent in Group B (P = 0.024). The age at presentation was younger than four years in 88 percent of patients in Group A vs. 58 percent in Group B (P = 0.019). CONCLUSIONS: Rectal prolapse in children does respond to conservative management. A decision to operate is based on age of patient, duration of conservative management, and frequency of recurrent prolapse (>2 episodes requiring manual reduction) along with symptoms of pain, rectal bleeding, and perianal excoriation because of recurrent prolapse. Those cases presenting younger than four years of age and with an associated condition have a better prognosis. The authors propose an algorithm for the management of rectal prolapse in children.

A Comparison of Open vs. Laparoscopic Abdominal Rectopexy for Full-Thickness Rectal Prolapse: A Meta-Analysis.
Purkayastha S, Tekkis P, Athanasiou T, Aziz O, Paraskevas P, Ziprin P, Darzi A.
Dis Colon Rectum 2005 Jun 20;.

PURPOSE: Using meta-analytical techniques, this study was designed to compare open and laparoscopic abdominal procedures used to treat full-thickness rectal prolapse in adults. METHODS: Comparative studies published between 1995 and 2003, cited in the literature of open abdominal rectopexy vs. laparoscopic abdominal rectopexy, were used. The primary end points were recurrence and morbidity, and the secondary end points assessed were operative time and length of hospital stay. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed. RESULTS: Six studies, consisting of a total of 195 patients (98 open and 97 laparoscopic) were included. Analysis of the data suggested that there is no significant difference in recurrence and morbidity between laparoscopic abdominal rectopexy and open abdominal rectopexy. Length of stay was significantly reduced in the laparoscopic group by 3.5 days (95 percent confidence interval, 3.1-4; P < 0.01), whereas the operative time was significantly longer in this group, by approximately 60 minutes (60.38 minutes; 95 percent confidence interval, 49-71.8). CONCLUSIONS: Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regards to recurrence and morbidity and favorably with length of stay. However large-scale randomized trials, with comparative, sound methodology are still needed to ascertain detailed outcome measures accurately.

Long-Term Results of Delorme's Procedure and Orr-Loygue Rectopexy to Treat Complete Rectal Prolapse.
Marchal F, Bresler L, Ayav A, Zarnegar R, Brunaud L, Duchamp C, Boissel P.
Dis Colon Rectum 2005 Jun 16;.

PURPOSE: The aim of this study was to assess long-term outcome of Orr-Loygue rectopexy and Delorme's procedures in total rectal prolapse management. METHODS: Data were collected retrospectively from 1978 to 2001. Statistical analysis was performed by chi-squared test and Student's t -test. RESULTS: One hundred nine patients underwent either a Orr-Loygue rectopexy (49 patients) or a Delorme's procedure (60 patients). Mean follow-up was 88 (range, 1-300) months. In the rectopexy group, the overall complication rate and the recurrence rate were 33 percent and 4 percent, respectively. In patients with preoperative constipation, this symptom was improved or completely resolved in 33 percent and worsened in 58 percent postoperatively. Seventy-three percent of patients with preoperative incontinence were continent or had continence improvement postoperatively. In Delorme's group, overall complication and recurrence rates were 15 percent and 23 percent, respectively. Mortality was 7 percent. In patients with preoperative constipation, this symtom was improved or completely resolved in 54 percent and worsened in 12.5 percent of patients postoperatively. Forty-two percent of patients with preoperative incontinence were continent or had continence improvement postoperatively. CONCLUSIONS: In this study, Orr-Loygue rectopexy had a lower long-term recurrence rate. However, this surgical procedure is associated with a higher complication rate. We believe that Delorme's procedure is still a valuable option in selected patients with postoperative minimal morbidity but higher recurrence rate.

Mucosal Flap Excision for Treatment of Remnant Prolapsed Hemorrhoids or Skin Tags After Stapled Hemorrhoidopexy.
Koh PK, Seow-Choen F. Dis Colon Rectum 2005 Jun 16;.

Stapled hemorrhoidopexy may leave residual skin tags or external components following its use in large prolapsed piles. Excision of redundant mucosa above the dentate line and reconstitution to the staple line reduces these prolapsed elements. We describe a novel technique that removes residual skin tags and piles while remaining true to the spirit of stapled hemorrhoidopexy.

Radiofrequency ablation and plication: a non-resectional therapy for advanced hemorrhoids.
Gupta PJ.
J Surg Res 2005;126(1):66-72.

BACKGROUND: Radio frequency ablation followed by plication of the hemorrhoidal mass for patients who would otherwise require hemorrhoidectomy is being practiced at our hospital since last 5 years. This procedure accomplishes hemorrhoidal symptom relief with far less post-operative pain and other complications as compared to various other types of hemorrhoidectomies. MATERIALS AND METHODS: A retrospective study of 1000 patients having grade III or grade IV hemorrhoids treated with the above technique over a period of 30 months is reported. A Ellman radiofrequency generator was used for ablation of the hemorrhoids. Follow-up record of these patients is presented. The post-operative outcome and procedure related complications are compared with conventional hemorrhoidectomy procedures. RESULTS: With this procedure, the post-defecation pain score reported was between 1 and 4 (VAS) in the first week, which subsided thereafter. There were 42% patients who had post-defecation bleeding in the first 10 days. There were 82% patients able to resume duties on the 6th post-operative day. Of these, 5% of the patients had post-operative urinary retention needing catheterization for a single time, and 18 patients required readmission for secondary bleeding. None of the patients complained of fecal incontinence, sepsis, or anal stenosis. In the subsequent follow-up at a mean of 19 months, 4% of the patients had residual skin tags, 3% of them had symptomatic anal papillae, and 2% developed recurrence of hemorrhoids. CONCLUSION: The combined procedure described above could be a feasible alternative for surgical treatment of hemorrhoids being quick and easy to perform. With this procedure, the hospital stay is short, post-operative pain is less, return to work is faster, and recurrence rate is low.

Correlation of Histology With Anorectal Function Following Stapled Hemorrhoidectomy.
Kam MH, Mathur P, Peng XH, Seow-Choen F, Chew IW, Kumarasinghe MP.
Dis Colon Rectum 2005 May 5;.

INTRODUCTION: The inadvertent removal of smooth muscle during the use of stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. We correlated the amount of smooth muscle removed with anorectal function in the early postoperative period. METHODS: Patients were assessed preoperatively with an Eypasch quality-of-life questionnaire and underwent anorectal manometry and physiology testing. This was followed by a similar examination at three months postoperatively. Patients were operated on by a single surgeon and the excised anorectal mucosa was sent for histologic examination. The amount of smooth muscle excised was expressed semiquantitatively as a percentage of the total tissue removed. RESULTS: Sixty-eight patients (33 males) were recruited prospectively, with median age of 44 years. Six patients were lost to follow-up. Removal of anal transitional zone did not increase the incidence of incontinence. Both median preoperative and postoperative continence scores were good. Only one patient had incontinence to gas as a result of the operation. Median preoperative and postoperative quality-of-life scores were 114 and 131, respectively, out of a total of 144, the higher postoperative scores showing an improvement. Correlation of quality-of-life scores and mean resting anal pressures with percentage of smooth muscle removed did not show any statistical significance. CONCLUSIONS: Some smooth muscle will invariably be excised in stapled hemorrhoidectomy but the amount of smooth muscle removed did not significantly affect the continence score, quality of life, or mean anal resting pressure after stapled hemorrhoidectomy. It remains a safe and preferred procedure for the treatment of hemorrhoids.

Local Anesthesia for Stapled Prolapsectomy in Day Surgery: Results of a Prospective Trial.
Mariani P, Arrigoni G, Quartierini G, Dapri G, Leone S, Barabino M, Opocher E.
Dis Colon Rectum 2005 May 3;.
PURPOSE: This article reports the results of a prospective trial of the feasibility of Longo's procedure under local anesthesia in day surgery. METHODS: From April 2002 to May 2003, 66 patients (42 males and 24 females) were enrolled in the study; the mean age was 47.5 (range, 23-65) years. Thirty-six patients (55 percent) had prolapsed third-degree hemorrhoids, while 30 (45 percent) had fourth-degree hemorrhoids. All patients were operated on under local infiltration of the anorectal region by injecting ropivacaine 7.5 mg/dl using a Quadrijet. During the surgical procedure, blood pressure and heart rate were always monitored and the level of pain was checked using a visual analog scale. Hospital discharge was programmed for 6:00 p.m. Any immediate complications, such as bleeding, urinary retention, or pain, were also recorded. RESULTS: It was possible to perform the procedure under local anesthesia in all patients, and the anesthesiologist did not need to intervene at any time. No vagal reaction was observed; the transient reduction of blood pressure and heart rate, which occurred in four patients (6 percent),was controlled with an analgesic drug. In 96 percent of the cases the mean intraoperative visual analog score was not higher than four. Fifty-six patients were discharged at 6:00 p.m., while only 10 percent required an overnight stay. CONCLUSIONS: The stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedure provides good pain control and results in a minimal number of complications.

[Rectal prolapse with acute transanal evisceration of the sigmoid colon]
Kunin N, Le Roy ML, Ollivier F, Morin-Chouarbi V, Verbrackel L.
Gastroenterol Clin Biol 2005 Apr;29(4):478-9.

Surgical management of hemorrhoids.
(SSAT).
J Gastrointest Surg 2005 Mar;9(3):455-6.

Prospective, Randomized Study: Proximate(R) PPH Stapler vs. LigaSure trade mark for Hemorrhoidal Surgery.

Kraemer M, Parulava T, Roblick M, Duschka L, Muller-Lobeck H.
Dis Colon Rectum 2005 May 31;.

PURPOSE: It has been shown that for hemorrhoidal surgery both LigaSuretrade mark and stapler cause less pain than diathermy or scissor dissection. This study has attempted to establish which of the less painful alternatives proves best in an unselected series of patients with hemorrhoidal disease. METHODS: Fifty patients were randomized to undergo stapling hemorrhoidopexy or LigaSuretrade mark hemorrhoidectomy. Parameters investigated were pain (primary parameter), patient satisfaction with treatment, and recovery of personal activity. Other factors investigated were operative result, ease of handling, analgesic requirements, and postoperative course. RESULTS: Both methods were found to be equivalent in all major aspects analyzed. Postoperative pain scores (P = 0.99), patient satisfaction (P = 1), and self-assessment of activity (P = 0.99) were almost identical in both groups of patients. Significant differences were found in none of the numerous factors investigated. CONCLUSION: Both methods can be used safely and without major disadvantage for the patient regardless of stage and extent of hemorrhoidal disease.

Ferguson Hemorrhoidectomy: Long-Term Results and Patient Satisfaction.
Guenin MO, Rosenthal R, Kern B, Peterli R, von Flue M, Ackermann C.
Dis Colon Rectum 2005 May 31;.

PURPOSE: Perioperative morbidity and long-term results after hemorrhoidectomy (Ferguson's technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy. METHODS: All records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients. RESULTS: Five-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22-96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1-7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases. CONCLUSION: Ferguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.

Comparison of laparoscopic and open surgery for total rectal prolapse.
Demirbas S, Akin ML, Kalemoglu M, Ogun I, Celenk T.
Surg Today 2005;35(6):446-52.

Total rectal prolapse is a devastating disorder causing constipation and anal incontinence. We compared open and laparoscopic surgical approaches in a limited series. METHODS: The subjects of this study were 23 patients who underwent laparoscopic procedures (LP group) and 17 patients who underwent open procedures (OP group) for rectal prolapse. We assessed the preoperative colonic transit time, postoperative pain scoring, pre- and postoperative anal functions, and changes in constipation and related symptoms. RESULTS: The median operation time was 140.8 min for the LP group and 113.1 min for the OP group (P = 0.037). The median postoperative hospital stay was 4.8 days after the LPs and 9.6 days after the OPs (P = 0.001). Less analgesia was needed in the early postoperative period after the LPs (P = 0.007). While more than 70% improvement in continence was seen in the patients who underwent OPs, it was about 85% in those who underwent LPs. Improvement in constipation and related symptoms were similar in both groups. More than 30% of patients still suffered from hard stools and other symptoms of constipation. The colonic transit times were reduced in about 50% of patients who had suffered constipation in both groups. There was no incidence of recurrence in the median follow-up period. CONCLUSION: Although transabdominal rectopexy has been performed conventionally for rectal prolapse for many years, laparoscopic rectopexy and laparoscopic resection rectopexy are associated with lower morbidity and less postoperative pain. We eliminated the total prolapse and cured incontinence in almost all patients, with a short hospital stay.

Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers.
Dvorkin LS, Gladman MA, Epstein J, Scott SM, Williams NS, Lunniss PJ.
Br J Surg 2005 May 16;.

BACKGROUND: Rectal intussusception is a common finding at evacuation proctography in both symptomatic and asymptomatic individuals. Little information exists, however, as to whether intussusception morphology differs between patients with evacuatory dysfunction and healthy volunteers. METHODS: Thirty patients (19 women; median age 44 (range 21-76) years) with disordered rectal evacuation, in whom an isolated intussusception was seen on proctography, were studied. Various morphological parameters were measured, and compared with those from 11 asymptomatic controls (six women; median age 30 (range 24-38) years) found, from 31 volunteers, to have rectal intussusception. Intussusceptum thickness greater than 3 mm was designated as full thickness. Intussuscepta impeding evacuation were deemed to be occluding. RESULTS: Twenty-two patients had full-thickness intussusception, compared with two controls (P = 0.003). Intussusceptum thickness was significantly greater in the symptomatic group (anterior component: P = 0.004; posterior: P = 0.011). Twenty patients in the symptomatic group, but only three subjects in the control group, had a mechanically occluding intussusception (P = 0.043), although only three patients demonstrated evacuatory dynamics outside the normal range. CONCLUSION: Rectal intussusception in patients with evacuatory dysfunction is more advanced morphologically than that seen in asymptomatic controls; it is predominantly full thickness in patients and mucosal in controls. However, caution is required when selecting patients for intervention based solely on radiological findings.

The "winged" circular anal dilator in stapled hemorrhoidopexy.
Altomare D.
Tech Coloproctol 2005 Apr;9(1):80; discussion 80.

Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation.
Pescatori M, Boffi F, Russo A, Zbar AP.
Int J Colorectal Dis 2005 Jun 10;.

BACKGROUND: Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty. PATIENTS AND METHODS: Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression. RESULTS: Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05). CONCLUSIONS: Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.

Complications and reoperations in stapled anopexy: learning by doing.
Jongen J, Bock JU, Peleikis HG, Eberstein A, Pfister K
Int J Colorectal Dis 2005 Jun 11;.

Although stapled anopexy for second and third degree hemorrhoids has been widely used since 1998, there are limited long-term data available. We performed an analysis of a prospectively accrued data set of all patients undergoing stapled anopexy in our practice from 1998 through August 2003. Patients were specifically assessed for early and late complications and long-term reoperation rates for anorectal pathology. We performed stapled anopexy in 654 patients (296 females) during the study period. Mean operation time was 21 min (5-70 min), and the postoperative stay was 3.6 days (1-13 days). Early postoperative complications: urinary retention, 42 patients (6.4%); fecal impaction, 18 (2.8%); postoperative hemorrhage, 26 (4.0%); thrombosed external hemorrhoid, four (0.6%); and fistula/abscess, nine (1.4%). Late postoperative complications: anastomotic dehiscence, 21 patients (3.2%); persistence of prolapse in three (0.5%); submucosal anastomotic cysts in four (0.6%); thrombosed external hemorrhoid in two (0.3%); skin tags in ten (1.5%); fissure in six (0.9%); proctitis in two (0.3%); and fecal incontinence in ten (1.5%). Reoperation was required in 50 patients (7.6%). Reoperation for complications within 30 days occurred in 42 patients (6.4%) for the following reasons: bleeding (23), dehiscence (five), thrombosed external hemorrhoid (three), fecal retention (two), fistula (three), fissure (five), and anal papilla (one). Reoperation for anorectal pathology after 30 days was required in 54 patients (8.3%) and was performed for the following: dehiscence/reprolapse (17), stenosis (two), submucous cyst (two), fistula (four), fissure (six), anal papilla (four), skin tags (five), persistent anal itching (five), and miscellaneous (seven). These data represent the largest series of patients with long-term follow-up following stapled anopexy and confirm that the operation is safe in experienced hands using appropriate patient selection. The early complication rate is low and similar to rates reported for excisional hemorrhoidectomy. Importantly, the procedure is associated with a low 3.4% rate of reoperation for persistence or recurrence of hemorrhoidal prolapse with good patient selection.

The effect of pudendal block on voiding after hemorrhoidectomy.
Kim J, Lee DS, Jang SM, Shim MC, Jee DL
Dis Colon Rectum 2005 Mar;48(3):518-23.

PURPOSE: Urinary retention in common benign anal surgery is a burden to ambulatory surgery. A pudendal nerve block was used in hemorrhoid surgery to reduce voiding complications. METHODS: The effects of a pudendal nerve block in anal surgery were compared with those of spinal anesthesia. In this prospective study, 163 consecutive patients who underwent elective hemorrhoids surgery by a single surgeon were randomized to receive pudendal nerve block (pudendal group) with 0.5 percent bupivacaine (n = 81) with 1:20,000 epinephrine or spinal anesthesia (spinal group) with 0.5 percentbupivacaine (n = 82). RESULTS: There were no statistically significant differences in the patient demographics, total amount of fluid administered, time to the onset of anesthesia, or intraoperative pain. All patients had a successful block during surgery. However, puborectalis muscle relaxation was not complete in the pudendal group. The time from the injection of the anesthetics to the first sensation of pain was longer in the pudendal group (9.1 vs. 3.1 hours; P < 0.001). Urinary catheterization was required in only 6 patients in the pudendal group compared with 57 patients in the spinal group (P < 0.001). The degree of pain was significantly lower in the pudendal group (2.7 vs. 5.2, Visual Analog Scale; P < 0.001). The amount of analgesics injected was significantly lower in the pudendal group (16/81 vs. 45/82; P < 0.001). CONCLUSIONS: A pudendal nerve block with bupivacaine results in fewer postoperative voiding complications and less pain compared with the traditional spinal anesthesia in a hemorrhoidectomy.

Sclerosing therapy of internal hemorrhoids with a novel sclerosing agent Comparison with ligation and excision.
Takano M, Iwadare J, Ohba H, Takamura H, Masuda Y, Matsuo K, Kanai T, Ieda H, Hattori Y, Kurata S, Koganezawa S, Hamano K, Tsuchiya S
Int J Colorectal Dis 2005 Apr 21;.

BACKGROUND AND AIMS: Patients with prolapsing internal hemorrhoids were treated with a novel sclerosing agent (OC-108), and the results were compared with surgery of ligation and excision. PATIENTS AND METHODS: This study included 20 years or older patients with prolapsing internal hemorrhoids who visited ten medical institutions in Japan from October 2000 to October 2002. Investigation on surgery was also performed. RESULTS: Comparing OC-108 and surgery in patients with third- and fourth-degree internal hemorrhoids according to the Goligher's classification, for which surgery has been generally indicated, at 28 days after treatment, the disappearance rate of prolapse was similar between OC-108 and surgery, 94% (75/80 patients) and 99% (84/85 patients), respectively. The 1-year recurrence rate was 16% (12/73 patients) in the OC-108 group, and this value was satisfactory because of its less invasive nature while it was more or less higher compared with 2% (2/81 patients) in the surgery group. The incidences of pain and bleeding were lower in the OC-108 group. CONCLUSIONS: OC-108 is a useful alternative treatment for hemorrhoids.

Prospective randomised clinical trial of single versus double purse-string stapled mucosectomy in the treatment of prolapsed haemorrhoids.
Perez-Vicente F, Arroyo A, Serrano P, Candela F, Sanchez A, Calpena R
Int J Colorectal Dis 2005 Apr 21;.

BACKGROUND AND AIMS: Despite the excellent results published on circular stapled mucosectomy (CSM), there is still some concern about the application of PPH-33 in the advanced haemorrhoidal disease, where a major prolapse may lead to insufficient resection and ensuing early recurrence. This study is aimed at comparing the outcomes after single purse-string CSM versus double purse-string CSM. PATIENTS AND METHODS: A prospective randomised clinical trial of single versus double purse-string CSM for grade III-IV symptomatic haemorrhoids was used. One hundred consecutive patients were randomised to single (group 1, N=50) versus double purse-string CSM (group 2, N=50). RESULTS: The mean age was 50.7 years, with a predominance of males (63 vs. 37). Haemorrhoids were classified as grade III in 59% and grade IV in 41% of the patients. Mean follow-up was 26 months. Demographic and clinical features showed no differences between the two groups. The size of the resected doughnut was greater in group 2 (4.95 vs. 3.55 cm; p<0.05), as was the distance of the suture from the dentate line (3.56 vs. 3.16 cm; p<0.05). Early postoperative pain was significantly less in group 2 (linear analogue scale from 0 to 10), 2.08 vs. 3.56 (p<0.001). Postoperative haemorrhage was absent or minimal in 79% of patients. Three patients from group 1 reported persistent pain that was resolved within the first few postoperative months. There were two recurrences in group 1. CONCLUSION: Double purse-string CSM resects a greater doughnut, increases the distance of the staple suture from the dentate line and reduces early postoperative pain in comparison to single purse-string CSM. Larger series are necessary to assert whether recurrence is lower.

Anterolateral rectopexy for correction of rectoceles leads to good anatomical but poor functional results.
Vermeulen J, Lange JF, Sikkenk AC, van der Harst E
Tech Coloproctol 2005 Apr;9(1):35-41.

BACKGROUND : Several different surgical repair procedures for symptomatic rectocele have been described with variable results. In our clinic, a modified anterolateral rectopexy is used. In this article we evaluate our results, with emphasis on patient satisfaction. METHODS : From 2001 until 2003, twenty patients with a symptomatic rectocele were treated by anterolateral rectopexy. The preoperative dynamic defecogram and anorectal complaints were analyzed and compared to postoperative outcome via a standardized questionnaire. RESULTS : After surgery, all rectoceles were restored as shown by postoperative defecogram. Anorectal symptoms (incomplete evacuation, continuous urge, prolapse, digital evacuation) were improved in 40%. As new-onset symptoms, dyspareunia (50%), digital support (55%) and incomplete evacuation (75%) were mentioned frequently. Most of the patients with larger rectoceles (>3.5 cm) had increased anorectal complaints after surgery. CONCLUSIONS : Anterolateral rectopexy for treatment of rectocele give limited improvement of anorectal complaints. Besides, many patients developed new complaints postoperatively and hence overall satisfaction was low.

Haemorrhoidectomy as a one-day surgical procedure: modified Ferguson technique.
Kosorok P, Mlakar B
Tech Coloproctol 2005 Apr;9(1):57-9.

Modification of Ferguson haemorrhoidectomy had been started because it was easier to ligate the haemorrhoidal pedicle with a rubber band instead of using the stitch. There is no need to use a retractor for such a procedure as it would cause discomfort to the patient when only infiltrative anaesthesia for one or two haemorrhoidal complexes was given. In the period from 1994 to 1999, we performed 398 haemorrhoidectomies as a one-day surgical procedure under local infiltrative anaesthesia. The examination follow-ups of the patients were performed and medical charts were reviewed. Early postoperative complications were rare: haemorrhage occurred in 1.8%, urine retention in 0.5%, high temperature in 1.3% and temporary incontinence in 0.3%. Overall, 28 patients (7%) had additional treatment for residual haemorrhoid problems 5-10 years after the primary haemorrhoidectomy was performed. We believe that our modified technique is a welcome alternative to the one-day surgical practice.

Transanal repair of rectocele and full rectal mucosectomy with one circular stapler: a novel surgical technique.
Regadas FS, Regadas SM, Rodrigues LV, Misici R, Silva FR, Regadas Filho FS
Tech Coloproctol 2005 Apr;9(1):63-6.

We present a new surgical stapling technique for treatment of rectocele when associated with internal mucosal prolapse or haemorrhoids using only one circular mechanical stapler. Eight female patients, mean age 53 years (range, 42-70), complaining of obstructed defecation with vaginal digitation because of rectocele associated with internal mucosal prolapse underwent transanal repair of rectocele and rectal mucosectomy using one circular stapler between April and July 2004. A running horizontal mattress suture was placed through the base of the rectocele including mucosa, submucosa and the muscle layer of the whole anterior anorectal junction wall. The prolapsed mucosa and the muscular layer were then excised with an electrical scapel. Acontinuous pursestring rectal mucosa suture was placed 0.5 cm before the previous anterior mucosa and muscle layers resected wound, including the anorectal junction wall which was kept separate from the posterior vaginal wall by a Babcock forceps. Posteriorly, the pursestring suture included only mucosal and submucosal layers. The stapled suture was positioned between normal anterior rectal wall and the anal canal, 0.5 cm above the pectinate line. The stapler was then closed, fired and withdrawn. One patient complained of a perianal hematoma on the seventh postoperative day, requiring surgical excision. Postoperative defecography showed correction of the rectocele and outlet obstruction disappeared in all patients. This novel combined manual-stapled technique for rectocele and rectal internal mucosal prolapse seems to be a safe procedure and the preliminary results are encouraging. Further investigations have to be performed to assess long-term outcome in a larger number of patients.

Pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema of the neck after stapled hemorrhoidopexy.
Filingeri V, Gravante G
Tech Coloproctol 2005 Apr;9(1):86.

Functional and Anatomic Outcome After Transvaginal Rectocele Repair Using Collagen Mesh: A Prospective Study.
Altman D, Zetterstrom J, Lopez A, Anzen B, Falconer C, Hjern F, Mellgren A
Dis Colon Rectum 2005 Apr 14;.

PURPOSE: This study was designed to evaluate rectocele repair using collagen mesh. METHODS: 32 female patients underwent surgical repair using collagen mesh. Outcome was assessed in 29 patients and preoperative assessment included standardized questionnaire, clinical examination, and defecography. At the six-month follow-up, patients answered a standardized questionnaire and underwent clinical examination. At the 12-month follow-up, patients answered a standardized questionnaire, underwent clinical examination, and defecography. RESULTS: Preoperatively, 26 patients had a Stage II and 3 patients had a Stage III rectocele. At the 6-month follow-up, five patients had rectocele >/= Stage II (P < 0.001) and at the 12-month follow-up, seven patients had rectocele >/= Stage II (P < 0.001) at clinical examination. At the preoperative defecography, all patients presented a rectocele. At the 12-month defecography, 14 patients had no rectocele (P < 0.001) and 15 had a rectocele. At the six-month follow-up, there was a significant decrease in rectal emptying difficulties, need of digital support of the posterior vaginal wall at defecation, and defecation frequency. At the 12-month follow-up, symptom improvement remained, but was less pronounced. CONCLUSIONS: Rectocele repair using collagen mesh improved anatomic support, but there is a substantial risk for recurrence with unsatisfactory anatomic and functional outcome one year after surgery. Rectocele repair using mesh was not associated with an increased risk of dyspareunia. Rectocele repair using biomaterial mesh reinforcement needs further evaluation before adopted into clinical practice.

Anal Stenosis After LigaSuretrade mark Hemorrhoidectomy.
Ramcharan KS, Hunt TM
Dis Colon Rectum 2005 Mar 22;.

Stapled Hemorrhoidopexy.
Ortiz H
Dis Colon Rectum 2005 Apr 14;.

The Authors Reply.
Khubchandani IT
Dis Colon Rectum 2005 Mar 21;.

Long-term outcomes of transanal rectocele repair.
Roman H, Michot F
Dis Colon Rectum 2005 Mar;48(3):510-7.

PURPOSE: This study was designed to assess the risk of rectocele recurrence after transanal repair and identify its predictive factors. METHODS: A series of 71 females who had undergone transanal repair of low isolated rectocele was retrospectively reviewed. The functional outcome was assessed by a standard questionnaire. The follow-up varied from 30 to 128 (mean, 74 +/- 30) months. Recurrences were evaluated by survival-analysis methods, and Cox's proportional hazar model was used to determine the optimal predictive factor for recurrence. RESULTS: Twenty-nine of 71 patients had isolated low rectocele recurrence, and 6 had a rectocele recurrence associated to an enterocele occurrence. The optimal predictive factor for rectocele recurrence was the persistence of symptoms two months after surgery. Although correlated to recurrences, preoperative manual pressure during defecation was not an independent predictive factor for recurrences. Preoperative defecographic parameters do not seem to influence clinical outcome of surgery, and preoperative manometric values did not determine which females could develop anal incontinence several years after surgery. CONCLUSIONS: The results of the transanal rectocele repair might progressively be worse during the length of the follow-up with a high recurrence rate (50 percent). Preoperative clinic, defecographic, or manometric parameters are not useful to identify females at risk for recurrence.

Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations.
Belizon A, Levitt M, Shoshany G, Rodriguez G, Pena A
J Pediatr Surg 2005 Jan;40(1):192-6; discussion 196.

PURPOSE: Rectal prolapse is a known postoperative problem in children with anorectal malformations. The aims of this study were to determine the incidence of significant rectal prolapse (>5 mm), to objectively quantify its predisposing factors, and to offer recommendations as to its prevention and surgical treatment. METHODS: The authors reviewed their series of 1619 patients with anorectal malformations; 1169 underwent primary posterior sagittal anorectoplasty (PSARP) at their institution between 1980 and 2002, and complete records were available for 833. The series was analyzed for incidence of prolapse, type of anorectal malformation, status of the sacrum, muscle quality, associated vertebral and spinal anomalies, and postoperative constipation. A specific technique for prolapse repair was used. RESULTS: Of 833 patients, 45 developed significant rectal prolapse (3.8%). The mean age at the time of PSARP was 0.73 years (range, 0.19-5 years). The average time to recognition of prolapse following PSARP was 13.1 months. Of these 45 patients, 32 required surgical repair and of those, 3 required a second surgical repair. The incidence of prolapse varied by complexity of anorectal defect: cloaca (6.2%), rectobladder neck fistula (6.8%), rectourethral fistula (5.4%), rectovestibular fistula (1.2%), rectal atresia (0%), and rectoperineal fistula (0%). There was a significantly increased incidence of prolapse in patients with a low muscle quality score and in patients with vertebral anomalies (20% vs 3.2%). The presence of a tethered cord and an abnormal sacral ratio did not correlate with an increased incidence of prolapse. Twenty-two patients developed prolapse following colostomy closure, and of these, 12 (55%) suffered from constipation. CONCLUSIONS: The overall incidence of significant rectal prolapse following PSARP is low. Prevention of prolapse with the PSARP technique may be because of key technical steps. Patients with higher anorectal malformations, poorer muscle quality, and vertebral anomalies had a greater risk of developing postoperative rectal prolapse. The presence of tethered cord and quality of the sacrum were not predictive of postoperative prolapse. Constipation seems to be a factor in the development of prolapse.

Complications of stapled hemorrhoidectomy: a French multicentric study.
Oughriss M, Yver R, Faucheron JL
Gastroenterol Clin Biol 2005 Apr;29(4):429-33.

OBJECTIVES: The aim of this retrospective multicentric study was to assess the complications of the Longo technique for the treatment of haemorrhoidal disease.METHODS: From March 1999 to April 2003, 550 patients underwent a stapled hemorrhoidectomy following Longo's technique in 12 surgical units in the Rhone-Alpes Region. The operative indications were the same as for conventional hemorrhoidectomy. Complications were divided into early or late complications depending on whether they occurred before or after the 7th day. For each patient, the most serious complication was retained for analysis.RESULTS: One hundred and five patients (19%), mean age 51 years, experienced complications. The early complications were bleeding (1.8%), severe anal pain (2.3%), urinary retention (0.9%) and sepsis (0.5%). Late complications were chronic anal pain (1.6%), suture dehiscence (1.6%), anal stricture (1.6%), anal fissure (0.9%), external thrombosis (0.9%), fistulae and intramural abscesses (0.9%), anal incontinence (0.3%), haemorrhoidal disease symptoms persistence or recurrence (3.2%). Strictures were successfully dilated, fissures were treated by sphincterotomy, external thromboses were excised and fistulae were laid open. Most of the recurrences were treated with the Milligan-Morgan hemorroidectomy technique.CONCLUSION: Complications may occur after stapled hemorrhoidopexy, some are particularly serious, especially bleeding and sepsis.

Endosonographic pattern of solitary polypoid rectal ulcer.
Cola B, Cuicchi D, Dalla Via B, Lecce F
Tech Coloproctol 2005 Apr;9(1):71-72.

[About "Is routine pathologic evaluation of hemorrhoidectomy specimens necessary?"]
Bauer P, De Parades V, Etienney I, Daniel F, Atienza P
Gastroenterol Clin Biol 2005 Feb;29(2):213-4; author reply 214-5.

Persistent rectal prolapse in children: sclerotherapy and surgical management.
Shah A, Parikh D, Jawaheer G, Gornall P
Pediatr Surg Int 2005 Mar 11;.

Persistent rectal prolapse is an uncommon but distressing condition in children. Significant controversy exists regarding its surgical management. The aim of this study was to identify a successful management strategy for persistent rectal prolapse in the paediatric population. Records of all children with rectal prolapse treated surgically at Birmingham Children's Hospital between 1995 and 2003 were retrospectively reviewed. Demographic data, clinical presentation, investigations, treatment modality, complications, and outcome were recorded. Inclusion criteria for the study were failure of conservative management leading to operative treatment. An exclusion criterion was cystic fibrosis. A total of 24 patients with persistent rectal prolapse were identified. Two children with cystic fibrosis were excluded from the analysis. Children below the age of 5 years, group I (n=17), were successfully managed by submucous hypertonic saline injections. Eighty-three percent (14/17) were cured by injection sclerotherapy in this group, 12/14 (71%) requiring one injection and 2/14 requiring a second injection. In the three (17.6%) children in group I in whom sclerotherapy failed, cow's milk protein (CMP) allergy was identified as the causative factor. Children older than 5, group II (n=5), either had behavioural problems (n=3) or were autistic (n=2). This group of children with adult-type, full-thickness rectal prolapse were found to be refractory to initial attempts of injection sclerotherapy. All five children were successfully managed with surgical correction. We conclude that rectal submucous hypertonic saline injections are highly effective for managing early-onset idiopathic childhood rectal prolapse. CMP allergy should be considered in young children with recurrent rectal prolapse. We recommend early definitive corrective surgery in older children with persistent rectal prolapse, as they do not respond to conservative measures or injection sclerotherapy.

Laparoscopic rectopexy for full-thickness rectal prolapse: a single-institution retrospective study evaluating surgical outcome.
Lechaux D, Trebuchet G, Siproudhis L, Campion JP
Surg Endosc 2005 Mar 11;.

BACKGROUND: The laparoscopic approach promises to become the gold standard for the transabdominal management of full-thickness rectal prolapse. The aim of this study was to review our experience and to highlight the functional results achieved with this new technique. uMETHODS: Forty-eight patients with full-thickness external prolapse underwent laparoscopic repair between February 1997 and February 2003. All patients underwent preoperative evaluation of their rectal function. Patients with isolated rectal ulcer without prolapse or with internal prolapse and patients deemed by the anesthesiologist to be unfit for general anesthesia were excluded from the study. The laparoscopic technique was either a mesh rectopexy without resection (n = 35) or a suture rectopexy with sigmoid resection (n = 13). Patients with intractable constipation preceding the development of the rectal prolapse were advised to have a resection-rectopexy. In the postoperative follow-up, attention was paid to mortality, morbidity, recurrent prolapse, incontinence, and constipation. Follow-up was done by clinical review and postal questionnaire. RESULTS: There were no deaths and no septic or anastomotic complications. The postoperative morbidity rate was 5%. Oral intake was started on postoperative day 1. Discharge from the hospital was on postoperative day 4 in patients without sigmoid resection and on postoperative day 7 in patients with sigmoid resection. Two patients (4%) developed recurrent total prolapse during a median follow-up period of 36 +/- 15 months (range, 7-77). The functional results were good or excellent in 72% of the cases, without digitations or dyschesia. Continence was improved in 31% of the patients and remains unchanged in 64% of them. In 11 patients (23%), constipation was worsened by the procedure. CONCLUSION: Laparoscopic rectopexy with or without resection is both safe and effective. Advantages include low-morbidity, improved cosmesis, the rapid return of intestinal function, early discharge from hospital, and a low recurrence rate. The fecal continence score is improved; however, constipation is frequently worsened.

EXternal Pelvic REctal SuSpension (Express procedure) for rectal intussusception, with and without rectocele repair.
Williams NS, Dvorkin LS, Giordano P, Scott SM, Huang A, Frye JN, Allison ME, Lunniss PJ
Br J Surg 2005 Mar 18;.

BACKGROUND: The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients. METHODS: Seventeen patients (13 women; median age 47 (range 20-67) years) with rectal evacuatory dysfunction and rectal intussusception, 13 of whom had a rectocele, were selected. The intussusception was corrected by external pelvic suspension of the rectum, using collagen strips attached to the rectal wall and pubis. The rectocele was repaired with a collagen patch. Patients were assessed before and 6 months after surgery by symptom and quality of life questionnaires, anorectal physiological investigation and proctography, and were followed up for a median of 12 months. RESULTS: Sepsis requiring exploration occurred in two patients but there was no extrusion or need to remove the collagen. Of the 15 patients assessed after surgery, total symptom scores were significantly decreased (P < 0.001) and quality of life scores improved (P < 0.001). Proctographically, the degree of intussusception was improved in ten patients; six patients had normal postoperative proctograms. The rectocele was reduced in size in all patients, and was not demonstrable in eight. CONCLUSION: An effective procedure for rectal intussusception and rectocele has been developed in a selected group of patients with marked evacuatory symptoms. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Intussusception in adults: an unusual and challenging condition for surgeons.
Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF
Int J Colorectal Dis 2005 Mar 10;.

BACKGROUND AND AIMS: Intestinal intussusception in adults is a rare entity and there is an ongoing controversy regarding the optimal management of this problem. The purpose of this study was to determine the causes and management of intussusception in adults. PATIENTS AND METHODS: A retrospective review of patients more than 18 years of age with a diagnosis of intestinal intussusception between January 1996 and December 2003 was conducted. Data related to presentation, diagnosis, treatment, and pathology were analyzed. FINDINGS: A total of 13 patients were operated on due to intestinal intussusception. There were 6 men and 7 women with a mean age of 45 years (range 24-61 years). Abdominal pain was the most common presenting complaint (100%). Eight (61.5%) patients presented with acute symptoms and underwent emergency laparotomy. The diagnosis of gastrointestinal intussusception was made preoperatively only in 4 (30.7%) patients by abdominal ultrasonography and computerized tomography. The lead point of intussusception was located in the small intestine in 10 (76.9%) patients, in the colon in 2 (15.4%), and in the ileocecal valve in 1 (7.7%). A pathologic cause for the intussusception was identified in 12 (92.3%) cases and 1 (7.7%) was idiopathic. Of the cases with a defined cause, 58% of the cases were benign and 42% were malignant. Forty percent of cases of small bowel intussusception and 33.3% of cases of colonic intussusception were due to malignant lesions. All cases of small intestinal intussusception were reduced and no perforation occurred. Segmental intestinal resection was performed in 9 patients and excision of the Meckel's diverticulum was made in 1. In cases of colonic intussusception, reduction was not attempted and en-bloc resection was carried out. No perforation or spillage of the contents of the intussusception was observed. There was no surgical mortality. CONCLUSION: Adult intussusception is an unusual and challenging condition that represents a preoperative diagnostic difficulty. We think that colonic intussusceptions should be resected in an en-bloc manner without reduction due to the risk of perforation and spillage of micro-organisms and malignant cells, whereas cases of small intestinal intussusception can be reduced without complications unless there is strangulation.

Rectal Intussusception: Characterization of Symptomatology.
Dvorkin LS, Knowles CH, Scott SM, Williams NS, Lunniss PJ
Dis Colon Rectum 2005 Mar 22;.

PURPOSE: Rectal intussusception is a common finding at evacuation proctography; however, its significance has been debated. This study was designed to characterize clinically and physiologically a large group of patients with rectal intussusception and test the hypothesis that certain symptoms are predictive of this finding on evacuation proctography. METHODS: A total of 896 patients underwent evacuation proctography from which three groups were identified: those with isolated rectal intussusception (n = 125), those with isolated rectocele (n = 100), and those with both abnormalities (n = 152). Multivariate analyses were used to identify symptoms predictive of findings by evacuation proctography. RESULTS: The symptoms of anorectal pain and prolapse were highly predictive of the finding of isolated intussusception over rectocele (odds ratio, 3.6, P = 0.006; odds ratio, 4.9, P < 0.001) or combined intussusception and rectocele (odds ratio, 2.9, P = 0.02; odds ratio, 2.4, P = 0.03). The symptom of "toilet revisiting" was associated with the finding of rectoanal intussusception (odds ratio, 3.55, P = 0.04). Although patients with mechanically obstructing intussuscepta evacuated slower and less completely (P < 0.001) than those with nonobstructing intussuscepta, no symptom was predictive of this finding on evacuation proctography. CONCLUSIONS: Although certain symptoms are predictive of the finding of rectal intussusception, there is a wide overlap with symptoms of rectocele, another common cause of evacuatory dysfunction. Furthermore, the observation that "obstruction to evacuation" made on proctography had no impact on the incidence of evacuatory symptoms suggests that beyond simply demonstrating the presence of an intussusception, analysis of proctography and subclassifying intussusception morphology seems of little clinical significance, and selection for surgical intervention on the basis of proctographic findings may be illogical.

Rectal Prolapse and Cap Polyposis: The Missing Link.
Daniel F, Atienza P
Dis Colon Rectum 2005 Mar 22;.

Laparoscopically-Assisted Resection Rectopexy for Rectal Prolapse: Ten Years' Experience.
Ashari LH, Lumley JW, Stevenson AR, Stitz RW
Dis Colon Rectum 2005 Mar 22;.

PURPOSE: This study has been undertaken to audit a single-center experience with laparoscopically-assisted resection rectopexy for full-thickness rectal prolapse. The clinical outcomes and long-term results were evaluated. METHODS: The data were prospectively collected for the duration of the operation, time to passage of flatus postoperatively, hospital stay, morbidity, and mortality. For follow-up, patients received a questionnaire or were contacted. The data were divided into quartiles over the study period, and the differences in operating time and length of hospital stay were tested using the Kruskal-Wallis test. RESULTS: Between March 1992 and October 2003, a total of 117 patients underwent laparoscopic resection rectopexy for rectal prolapse. The median operating time during the first quartile (representing the early experience) was 180 minutes compared with 110 minutes for the fourth quartile (Kruskal-Wallis test for operating time = 35.523, 3 df, P < 0.0001). Overall morbidity was 9 percent (ten patients), with one death (<1 percent). One patient had a ureteric injury requiring conversion. One minor anastomotic leak occurred, necessitating laparoscopic evacuation of a pelvic abscess. Altogether, 77 patients were available for follow-up. The median follow-up was 62 months. Eighty percent of the patients reported alleviation of their symptoms after the operation. Sixty-nine percent of the constipated patients experienced an improvement in bowel frequency. No patient had new or worsening symptoms of constipation after surgery. Two (2.5 percent) patients had full-thickness rectal prolapse recurrence. Mucosal prolapse recurred in 14 (18 percent) patients. Anastomotic dilation was performed for stricture in five (4 percent) patients. CONCLUSIONS: Laparoscopically-assisted resection rectopexy for rectal prolapse provides a favorable functional outcome and low recurrence rate. Shorter operating time is achieved with experience. The minimally invasive technique benefits should be considered when offering rectal prolapse patients a transabdominal approach for repair, and emphasis should now be on advanced training in the laparoscopic approach.

Stapled Hemorrhoidopexy vs. Diathermy Excision for Fourth-Degree Hemorrhoids: A Randomized, Clinical Trial and Review of the Literature.
Ortiz H, Marzo J, Armendariz P, De Miguel M
Dis Colon Rectum 2005 Mar 22;.

PURPOSE: The 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. METHODS: Thirty-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. RESULTS: The 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). CONCLUSIONS: Stapled 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.

Reduction of a Large Incarcerated Rectal Prolapse By Use of an Elastic Compression Wrap.
Sarpel U, Jacob BP, Steinhagen RM
Dis Colon Rectum 2005 Mar 23;.

Reduction of a large rectal prolapse may be difficult because of significant edema that collects in the rectal tissues. If reduction is unsuccessful, an emergent laparotomy and internal reduction is required. A wide elastic wrap applied around the prolapsed rectum provides progressive compression, which reduces the amount of edema, allowing subsequent manual reduction. This novel technique is simple, safe, inexpensive, and can easily be performed in the emergency department setting. Manual reduction, by this or other described methods, should be attempted before emergent laparotomy for incarcerated rectal prolapse is performed.

Laparoscopic or Transanal Repair of Rectocele? A Retrospective Matched Cohort Study.
Thornton MJ, Lam A, King DW
Dis Colon Rectum 2005 Mar 22;.

PURPOSE: The aim of the study was to analyze the functional and physiologic outcome of patients undergoing laparoscopic rectocele repair compared to a matched cohort undergoing transanal repair. METHODS: Forty patients with a rectocele who had undergone laparoscopic pelvic floor repair by a laparoscopic gynecologist were matched for age and rectocele size with 40 patients who had undergone a transanal repair by a colorectal surgeon. All patients had clinical evidence of a symptomatic rectocele. All patients were assessed postoperatively with a quality of life (SF-36) score, a modified St. Mark's continence score, a urinary dysfunction score, a Watt's sexual dysfunction score, and a linear analog patient satisfaction score. Fifteen patients in each group had also undergone preoperative and postoperative anal manometry. RESULTS: At 44 months median follow-up, the transanal approach resulted in significantly more patients reporting bowel symptom alleviation (P < 0.002) and higher patient satisfaction (P < 0.003). The bowel symptom improvement was also sustained over a significantly longer period (P < 0.03). Only 11 patients (28 percent) in the laparoscopic group reported more than 50 percent improvement in their bowel symptoms compared to 25 patients (63 percent) in the transanal group. On univariate analysis of 50 percent bowel symptom improvement, a larger rectocele (P < 0.009), transanal repair (P < 0.02), and presenting with obstructive defecation rather than fecal incontinence (P < 0.03) were statistically significant. Rectocele size (P < 0.012) and treatment cohort (P < 0.006) remained significant on multivariate analysis. Postoperatively, bowel symptom alleviation correlated with patient satisfaction in both groups (P < 0.015). Although not statistically significant, five patients (13 percent) in the transanal group developed postoperative fecal incontinence, which was associated with a low maximum anal resting pressure preoperatively that was further diminished postoperatively (P > 0.06). Only one patient (3 percent) in the laparoscopic group reported a decline in fecal continence, but four patients (10 percent) reported worsening of their symptoms of obstructed defecation. Postoperative dyspareunia was reported by 24 patients in total (30 percent), with significantly more in the transanal group (P > 0.05). CONCLUSIONS: The transanal repair results in a statistically greater alleviation of bowel symptoms and greater patient satisfaction scores. However, this approach may have a greater degree of functional co-morbidity than the laparoscopic rectocele repair.

Unusual complication of rectopexy with polypropylene mesh.
Singhal R, Tyagi SK, Nagar AM
Int J Colorectal Dis 2005 Mar 8;.

Long-Term Results of the Anterior Delorme's Operation in the Management of Symptomatic Rectocele.

Abbas SM, Bissett IP, Neill ME, Macmillan AK, Milne D, Parry BR
Dis Colon Rectum 2005 Feb;48(2):317-22.

PURPOSE: Although the results of surgery for symptomatic rectocele seem satisfactory initially, there is a trend toward deterioration with time. This study was designed to assess the long-term outcome of Anterior Delorme's operation for rectocele. METHODS: Questionnaires were sent to all females who had Anterior Delorme's operation performed in Auckland between 1990 and 2000. The questionnaires included obstructed defecation symptoms and a validated fecal incontinence severity index questionnaire and fecal incontinence quality of life questionnaire. Preoperative and postoperative obstructed defecation symptoms and incontinence score were compared. RESULTS: A total of 150 females (mean age, 56 (range, 30-83) years) who had an Anterior Delorme's operation for a rectocele were identified. One hundred seven patients (71.5 percent; mean age, 56 years) completed the questionnaire. Median follow-up was four (range, 2-11) years. The number of patients with obstructed defecation reduced from 87 preoperatively to 23 postoperatively using Rome II criteria (P < 0.0001). Postoperatively there was a reduction in the number of patients with each of the symptoms of obstructed defecation from 83 to 27 for straining, 87 to 33 for incomplete emptying, 64 to 14 for feeling of blockage, 41 to 10 for digitation (P < 0.0001 for all). The median incontinence score reduced from 20 of 61 preoperatively to 12 of 61 postoperatively (P = 0.0001). CONCLUSIONS: In patients with symptomatic rectocele, Anterior Delorme's operation provides long-term benefit for patients with obstructed defecation and leads to a significant improvement of incontinence scores.

Stapled Hemorrhoidopexy vs. Harmonic Scalpeltrade mark Hemorrhoidectomy: A Randomized Trial.
Chung CC, Cheung HY, Chan ES, Kwok SY, Li MK
Dis Colon Rectum 2005 Mar 24;.

PURPOSE: A randomized trial was undertaken to evaluate and compare stapled hemorrhoidopexy with excisional hemorrhoidectomy in which the Harmonic Scalpeltrade mark was used. METHODS: Patients with Grade III hemorrhoids who were employed during the trial period were recruited and randomized into two groups: (1) Harmonic Scalpeltrade mark hemorrhoidectomy, and (2) stapled hemorrhoidopexy. All operations were performed by a single surgeon. In the stapled group, the doughnut obtained was sent for histopathologic examination to determine whether smooth muscles were included in the specimen. Operative data and complications were recorded, and patients were followed up through a structured pro forma protocol. An independent assessor was assigned to obtain postoperative pain scores and satisfaction scores at six-month follow-up. Patients were also administered a simple questionnaire at follow-up to assess continence functions. RESULTS: Over a 20-month period, 88 patients were recruited. The two groups were matched for age and gender distribution. No significant difference was identified between the two groups in terms of operation time, blood loss, day of first bowel movement after surgery, and complication rates. Despite a similar parenteral and oral analgesic requirement, the stapled group had a significantly better pain score (P = 0.002); these patients also had a significantly shorter length of stay (P = 0.02), and on average resumed work nine days earlier than the group treated with the Harmonic Scalpeltrade mark (6.7 vs. 15.6, P = 0.002). Although 88 percent of doughnuts obtained in the stapled group contained some smooth muscle fibers, no association was found between smooth muscle incorporation and postoperative continence function, and as a whole the continence outcomes of the stapled group were similar to those after Harmonic Scalpeltrade mark hemorrhoidectomy. Finally, at six-month follow-up, patients who underwent the stapled procedure had significantly better satisfaction scores (P = 0.001). CONCLUSION: Stapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.

Recurrence Rates After Abdominal Surgery for Complete Rectal Prolapse: A Multicenter Pooled Analysis of 643 Individual Patient Data.
Raftopoulos Y, Senagore AJ, Di Giuro G, Bergamaschi R
Dis Colon Rectum 2005 Mar 24;.

PURPOSE: This study was designed to determine what impact surgical technique, means of access, and method of rectopexy have on recurrence rates following abdominal surgery for full-thickness rectal prolapse. METHODS: Consecutive individual patient data on age, gender, surgical technique (mobilization-only, mobilization-resection-pexy, or mobilization-pexy), means of access (open or laparoscopic), rectopexy method (suture or mesh), follow-up length, and recurrences were collected from 15 centers performing abdominal surgery for full-thickness rectal prolapse between 1979 and 2001. Recurrence was defined as the presence of full-thickness rectal prolapse after abdominal surgery. Chi-squared test and Cox proportional hazards regression analysis were used to assess statistical heterogeneity. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively. RESULTS: Abdominal surgery consisted of mobilization-only (n = 46), mobilization-resection-pexy (n = 130), or mobilization-pexy (n = 467). There were 643 patients. After excluding center 8, there was homogeneity on recurrence rates among the centers with recurrences (n = 8) for age (hazards ratio, 0.6; 95 percent confidence interval, 0.2-1.7; P = 0.405), gender (hazards ratio, 0.6; 95 percent confidence interval, 0.1-2.3; P = 0.519), and center (hazards ratio, 0.3; 95 percent confidence interval, 0.1-1.5; P = 0.142). However, there was heterogeneity between centers with (n = 8) and without recurrences (n = 6) for gender (P = 0.0003), surgical technique (P < 0.0001), means of access (P = 0.01), and rectopexy method (P < 0.0001). The median length of follow-up of individual centers varied from 4 to 127 months (P < 0.0001). There were 38 recurrences at a median follow-up of 43 (range, 1-235) months. The pooled one-, five-, and ten-year recurrence rates were 1.06, 6.61, and 28.9 percent, respectively. Age, gender, surgical technique, means of access, and rectopexy method had no impact on recurrence rates. CONCLUSIONS: Although this study is likely underpowered, the impact of mobilization-only on recurrence rates was similar to that of other surgical techniques.

Sacral Nerve Stimulation for Fecal Incontinence Following Surgery for Rectal Prolapse Repair: A Multicenter Study.
Jarrett ME, Matzel KE, Stosser M, Baeten CG, Kamm MA
Dis Colon Rectum 2005 Mar 24;.

PURPOSE: A proportion of patients have fecal incontinence secondary to a full-thickness rectal prolapse that fails to resolve following prolapse repair. This multicenter, prospective study assessed the use of sacral nerve stimulation for this indication. METHODS: Patients had to have more than or equal to four days with fecal incontinence per 21-day period more than one year after surgery. They had to have failed conservative treatment and have an intact external anal sphincter. RESULTS: Four female patients aged 42, 54, 68, and 65 years met the inclusion criteria. Three of the four patients had had more than one operation for recurrent full-thickness rectal prolapse before sacral nerve stimulation, one of whom had undergone a further operation for recurrence following stimulation. One patient had undergone one operation for prolapse repair. The preoperative duration of symptoms was ten, eight, three, and nine years, respectively. Although patients had an intact external anal sphincter, one patient had a fragmented internal anal sphincter. The frequency of fecal incontinent episodes changed from 11, 24.7, 5, and 8 per week at baseline to 0, 1.5, 5.5, and 1 per week at latest follow-up. Ability to defer defecation was also improved in two of three patients who had this documented. Fecal incontinence-specific quality of life assessment showed an improvement in all four domains. CONCLUSION: Sacral nerve stimulation should be considered for patients with ongoing fecal incontinence following full-thickness rectal prolapse repair if they prove resistant to conservative treatment.

Is routine pathologic evaluation of hemorrhoidectomy specimens necessary?

Lemarchand N, Tanne F, Aubert M, Benfredj P, Denis J, Dubois-Arnous N, Fellous K, Ganansia R, Senejoux A, Soudan D, Puy-Montbrun T
Gastroenterol Clin Biol 2004 Aug-Sep;28(8-9):659-61.

AIM: To confirm that systematic histological study of hemorrhoidectomy specimens is useless, as is proposed by the French Society of Coloproctology (Societe Nationale Francaise de Colo-Proctologie) under the sponsorship of the French National Health Accreditation and Evaluation Agency (Agence Nationale d'Accreditation et d'Evaluation en Sante). METHODS: Retrospective histological analysis of hemorrhoidectomy specimens obtained in a coloproctology unit between January 1, 1985 and December 31, 2001. RESULTS: We found 56 histological abnormalities (0.69%) among 8153 hemorrhoidectomy specimens considered normal at gross examination, with three cases of intraepithelial neoplasia of the anal canal (0.04%) and four cases of severe dysplasia (0.05%). Specimens associated with anal fissure (N = 906) or suppuration (N = 610) did not display more histological lesions. For all patients, the initial surgical resection prevented recurrence. CONCLUSION: Routine pathological evaluation of hemorrhoidectomy specimens is not useful and is expensive. All operating procedures in proctology should reflect this attitude. It is nevertheless advisable to select for gross and microscopic evaluation any suspicious areas noticed at the preoperative examination or during the procedure.

Surgical management of rectal prolapse.
Madiba TE, Baig MK, Wexner SD
Arch Surg 2005 Jan;140(1):63-73.

BACKGROUND: The problem of complete rectal prolapse is formidable, with no clear predominant treatment of choice. Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation with acceptable mortality and recurrence rates. Abdominal procedures are ideal for young fit patients, whereas perineal procedures are reserved for older frail patients with significant comorbidity. Laparoscopic procedures with their advantages of early recovery, less pain, and possibly lower morbidity are recently added options. Regardless of the therapy chosen, matching the surgical selection to the patient is essential. OBJECTIVE: To review the present status of the surgical treatment of rectal prolapse. DATA SOURCES: Literature review using MEDLINE. All articles reporting on rectopexy were included. STUDY SELECTION: Articles reporting on prospective and retrospective comparisons were included. Case reports were excluded, as were studies comparing data with historical controls. DATA EXTRACTION: The results were tabulated to show outcomes of different studies and were compared. Studies that did not report some of the outcomes were noted as "not stated." DATA SYNTHESIS: Abdominal operations offer not only lower recurrence but also greater chance for functional improvements. Suture and mesh rectopexy produce equivalent results. However, the polyvinyl alcohol (Ivalon) sponge rectopexy is associated with an increased risk of infectious complications and has largely been abandoned. The advantage of adding a resection to the rectopexy seems to be related to less constipation. Laparoscopic rectopexy has similar results to open rectopexy but has all of the advantages related to laparoscopy. Perineal procedures are better suited to frail elderly patients with extensive comorbidity. CONCLUSIONS: Abdominal procedures are generally better for young fit patients; the results of all abdominal procedures are comparable. Suture and mesh rectopexy are still popular with many surgeons-the choice depends on the surgeon's experience and preference. Similarly, the procedure may be done through a laparoscope or by laparotomy. Perineal procedures are preferable for patients who are not fit for abdominal procedures, such as elderly frail patients with significant comorbidities. The decision between perineal rectosigmoidectomy and Delorme procedures will depend on the surgeon's preference, although the perineal rectosigmoidectomy has better outcomes.

Perirectal haematoma and hypovolaemic shock after rectal stapled mucosectomy for haemorrhoids.
Grau LA, Budo AH, Fantova MJ, Sala XS
Int J Colorectal Dis 2005 Jan 28;.

Abdominal rectopexy for complete rectal prolapse: preliminary results of a new technique.
Di Giorgio A, Biacchi D, Sibio S, Accarpio F, Sinibaldi G, Petrella L, Cappiello FR, Sammartino P
Int J Colorectal Dis 2005 Mar;20(2):180-9. Epub 2004 Nov 20.

PURPOSE: Although the technique for the surgical repair of rectal prolapse has advanced over the years, no ideal procedure has been found. We aim to test a new surgical procedure for abdominal rectopexy that uses the greater omentum to support the rectum below the rectopexy, to reconstruct the anorectal angle and dispense with the need for synthetic mesh, thus reducing the risk of infection.METHODS: A series of ten patients, all young and medically fit, underwent repair surgery for rectal prolapse with the new rectopexy technique. Some patients had concomitant sigmoidectomy. Preoperative and postoperative assessment included a clinical examination, anal manometry and defecography.RESULTS: Follow-up lasted a mean of 56.4 months. None of the patients had recurrent rectal prolapse or infection. Postoperative assessment at 24 months disclosed significant improvements in all the bowel and sphincter variables assessed. The 8 patients who had severe incontinence preoperatively had notably improved and 4 were fully continent, 3 moderately incontinent, and only 1 patient had persistently high levels of incontinence. In only 1 patient who initially had severe incontinence, continence completely regressed and severe constipation developed. Maximal basal pressure values increased significantly after surgery (p=0.0025), although they increased slightly less evidently in patients in whom marked incontinence persisted at postoperative follow-up. Maximal voluntary contraction pressure also increased significantly after surgery (p=0.0054), although the values changed less than those for basal pressure. During rest, squeeze and straining, and in all the patients who regained continence, even those who recovered it only partly, surgery substantially reduced the anorectal angle. The reduction during rest was statistically significant (p=0.0062).CONCLUSIONS: The rectopexy technique we tested in patients with rectal prolapse avoids the need for synthetic mesh, and provides good results in terms of bowel and sphincter function, without infection or recurrence.

Open vs. closed hemorrhoidectomy.
You SY, Kim SH, Chung CS, Lee DK
Dis Colon Rectum 2005 Jan;48(1):108-13.

PURPOSE: This prospective, randomized, clinical trial compared the outcome of surgical hemorrhoidectomy by open and closed techniques in terms of postoperative pain, wound healing, and morbidity. METHODS: All consecutive patients with Grade III internal hemorrhoids with prominent external components or Grade IV hemorrhoids were randomly allocated to one of two groups. The entire wound was left open in the open group and completely closed using 5-0 chromic sutures in the closed group. Postoperative pain was assessed by a linear analog scale. Additional consumption of oxycodone hydrochloride on the day of surgery and at defecation during the first week was recorded. Patients were followed up 1, 2, and 3 weeks after the procedure. RESULTS: There were 40 patients in each group. Pain score at recovery from the anesthesia was significantly lower in the closed group (P < 0.05). Altogether, 15 percent of patients in the closed group required additional oxycodone hydrochloride for pain compared to 45 percent in the open group (P < 0.01). The pain score at the first bowel movement was significantly lower in the closed group (P < 0.01). Wound healing was significantly faster in the closed group: 75 percent of patients in the closed group had healed at 3 weeks after the procedure compared to 18 percent in the open group (P < 0.001). CONCLUSIONS: The closed technique is more advantageous with respect to less pain during the early postoperative period and faster wound healing.

Bowel habits in hemorrhoid patients and normal subjects.
Johannsson HO, Graf W, Pahlman L
Am J Gastroenterol 2005 Feb;100(2):401-6.

OBJECTIVES: Bleeding, pain, soiling, and prolapse are the classic symptoms in hemorrhoid disease, but the patients sometimes report a variety of other symptoms. Little is known about functional bowel symptoms in patients with hemorrhoids and few studies have previously addressed this subject. The aim of this study was to compare patients with hemorrhoids with a control population regarding functional bowel symptoms and anorectal complaints. MATHODS: One hundred consecutive patients who participated in a randomized study on hemorrhoidectomy completed a validated questionnaire on bowel and anorectal functional symptoms. Two hundred age- and gender-matched population based control subjects, and 100 gender-matched consecutive patients undergoing an orthopedic procedure served as two control groups, and completed the same questionnaire. RESULTS: Bowel frequency was the same in all three groups, but only 37% of the patients described their bowel movements as normal, compared to 55 and 67% of the controls (p < 0.001). Up to 37% of the patients reported bloating, compared to 18 and 26% in the control groups. Abdominal pain associated with bowel evacuation was experienced by 34% of the patients but in 3 and 5% of the controls (p < 0.001). Excessive straining, feeling of incomplete evacuation, and repeated toilet visits were significantly more usual in the patients. Reduced feeling of well being and disturbed social life caused by bowel symptoms was often reported by patients but rarely in the control groups. CONCLUSIONS: Beside hemorrhoidal symptoms, many patients with Grade 3-4 hemorrhoids have concomitant functional bowel symptoms, possibly associated with the irritable bowel syndrome. This knowledge might be important while selecting therapy for patients with hemorrhoids. (Am J Gastroenterol 2005;100:1-6).

Site-Specific Rectocele Repair Compared With Standard Posterior Colporrhaphy.
Abramov Y, Gandhi S, Goldberg RP, Botros SM, Kwon C, Sand PK
Obstet Gynecol 2005 Feb;105(2):314-318.

OBJECTIVE: To compare the anatomic and functional outcomes of site-specific rectocele repair and standard posterior colporrhaphy. METHODS: We reviewed charts of all patients who underwent repair of advanced posterior vaginal prolapse in our institution between July 1998 and June 2002 with at least 1 year of follow-up. RESULTS: This study comprised 124 consecutive patients following site-specific rectocele repair and 183 consecutive patients following standard posterior colporrhaphy without levator ani plication. Baseline characteristics, including age, body mass index, parity, previous pelvic surgeries, and preoperative prolapse were not significantly different between the 2 study groups. Recurrence of rectocele beyond the midvaginal plane (33% versus 14%, P = .001) and beyond the hymenal ring (11% versus 4%, P = .02), recurrence of a symptomatic bulge (11% versus 4%, P = .02), and postoperative Bp point (-2.2 versus -2.7 cm, P = .001) were significantly higher after the site-specific rectocele repair. Rates of postoperative dyspareunia (16% versus 17%), constipation (37% versus 34%), and fecal incontinence (19% versus 18%) were not significantly different between the 2 study groups. CONCLUSION: Site-specific rectocele repair is associated with higher anatomic recurrence rates and similar rates of dyspareunia and bowel symptoms than standard posterior colporrhaphy. LEVEL OF EVIDENCE: II-3.

Identification of differentially expressed genes in primary varicose veins.
Kim DI, Eo HS, Joh JH
J Surg Res 2005 Feb;123(2):222-6.

BACKGROUND: A number of changes in protein expression have been described in primary varicose veins, but the altered gene expressions in this disease are unknown. The aim of this study was to identify differentially expressed genes in primary varicose veins. MATERIALS AND METHODS: Total RNAs were isolated from two groups of greater saphenous veins (four primary varicose veins and three normal) and then were reverse transcribed into cDNAs. We used the differential display reverse transcription-polymerase chain reaction technique to screen the differences in the mRNA expression profiles of the groups. RESULTS: We found that three cDNAs showed differences in expression patterns between normal and diseased saphenous veins. The cDNAs are prominently expressed only in patients with varicose veins. We identified that the cDNAs had significant similarities to the L1M4 repeat sequence of clone RP11-57L9, clone RP11-299H13, and Alu repetitive sequence of human tropomyosin 4 mRNA. CONCLUSIONS: Our results suggest that the screened cDNA clones are useful disease markers in the genetic diagnosis of primary varicose vein and that the L1 and Alu elements possibly participated in the development of primary varicose veins through their expression patterns in genes encoded with structural proteins, such as collagen, elastin, and tropomyosin. Further studies are required to elucidate the potential relationship between repeat sequences and primary varicose veins.

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