Dynamic graciloplasty: a small and salutary experience

The Colorectal Unit at the King Faisal Specialist Hospital and Research Centre was one of 12 centers involved in the first international multicenter trial of dynamic graciloplasty. Some complications and problems related to the procedure were specific to Saudi Arabia, and this paper documents this experience in more detail. Patients and Patients with a generalized anal sphincter weakness were offered dynamic graciloplasty. Prior to surgery, patients underwent manometric examination of their sphincters. A right gracilis transposition was undertaken. After six weeks, a pulse generator was implanted and electrodes were inserted. The stimulation program commenced four weeks later. The neosphincter was magnetically controlled to allow defecation. Patients were followed at 3-monthly intervals to assess clinical progress. Five patients [3 males and 2 females] were considered to be suitable for the procedure. One patient developed an infection of the thigh wound which resolved without drainage. There was no other surgical morbidity. Mean resting [26.4 mm Hg] and "squeeze" [51.4 mm Hg] pressures prior to surgery were low. Following implantation, mean resting and "squeeze" pressures rose during training in 4 patients [48.5 and 100.8 mm Hg, respectively]. Two patients maintained satisfactory clinical and manometric function at 6 and 5 years' follow-up. One patient ceased to have any function in the transposed muscle and refused a further graciloplasty four years after graciloplasty. Another patient avulsed the leads and the transposed tendon on two occasions, and failed to heed advice given regarding posture and sitting. The final patient had an unsatisfactory wrap because of massive peri-rectal fibrosis. There was a 50% reduction in bowel frequency in the two patients in whom the procedure was successful. The technique requires a high level of patient cooperation, but should be available in specialized centers for the management of patients with refractory anal incontinence

Restorative proctocolectomy - a nine years experience at the King Faisal Specialist Hospital

Inflammatory bowel disease and Familial Adenomatous Polyposis [FAP] are relatively uncommon in Gulf Arabs. Restorative proctocolectomy with ileal pouch-anal anastomosis [IPAA] is a surgical methods for treating patients with mucosal ulcerative colitis [MUC] and FAP. This paper documents a small experience with this operation in Saudi Arabia. the charts of all patients who had either MUC or FAP and in whom an IPAA had been performed were identified and were examined in order to determine patient demographics, timing and staging of operation, operative and long term morbidity and mortality and pouch function. Thirty patients underwent IPAA. There were 16 males 29 pouches were J- Pouches. 1 patient was lost to follow up. Surgery was performed for fulmination MUC in 9 patients, failed medical treatment in 12, FAP in 7 and megacolon in 2.An emergency- three stage IPAA was performed in 10 patients. 3 patients received perioperative TPN.17 were on steroid medication.12 developed transient anastomotic stricture. 8 developed small bowel obstruction during follow up but none needed further surgery. 1 patient developed 'pouchitis'. Two pouches were removed. The mean daily and noctural bowel frequency was 6 and 2 motions per day.6 patients suffered nocturnal leakage. The operation of restorative proctocolectomy can be performed safely, for the few patients who needed the operation in Saudi Arabia

Squamous cell carcinoma of the anal region at the King Faisal Specialist Hospital and Research Centre

This study documents the epidemiological aspects of squamous cell carcinoma of the anus and anal canal as it has presented to the King Faisal Specialist Hospital and Research Centre [KFSH and RC]. Thirty-eight [33 Saudis] patients, 24 males and 14 females were studied. They ranged in age from 32 to 100 years. Twenty-four had anal canal tumors and 12 had anal margin cancers. Riyadh, the Eastern Province or Medina provided most patients and the majority presented with bleeding, a lump or pain. Symptom duration ranged from one month to more than two years. Fourteen had previous anal problems. There was an almost equal distribution of lesions between the anterior and posterior halves of the anus. Nineteen had clinically normal inguinal nodes. Thirty had squamous cell carcinoma [epidermoid] and eight had cloacogenic / basiloid tumors. Most tumors were either moderately or poorly differentiated. Twenty-eight presented with T[3] or T[4] tumors and only ten presented with T[1], or T[2] tumors. Five had evidence of metastases at initial presentation. Eight were treated by abdominoperinal resection of the rectum. A diversion colostomy was performed in six. Fifteen received radiotherapy alone but only three were treated by chemotherapy alone. Combination chemotherapy and radiotherapy was given to 14. More males than females had both anal canal and anal margin tumors. Patients with anal margin tumors were on average ten years older. There were twice as many with anal canal as anal margin tumors. There were more node-positive patients with anal margin tumors. Anal canal tumors were less well-differentiated. Follow-up was inadequate

Malignant neoplasia of the colon, rectum and anus at the King Faisal Specialist Hospital and Research Centre

Malignant neoplasms of the colon, rectum, and anus are relatively uncommon in the Kingdom of Saudi Arabia. This paper documents the King Faisal Specialist Hospital and Research Centre tumor registry colorectal cancer data base. Between June 1975 and December 1989, 622 patients were registered with malignant colorectal and anal tumors. There were 383 males and 239 females. The average ages were 53.5 years and 47.8 years. The majority of patients were Saudi. The single most common site for large bowel malignancy was the rectum. There were 455 simple adenocarcinomata, 39 mucinous adenocarcinomata, and 17 signet-ring adenocarcinomata. There were 46 epidermoid cancers. Most of the tumors were moderately differentiated and the majority of tumors were greater than 5 cm in diameter. Fifty-seven patients had disease localized to the organ of origin, 56 patients had disease which was localized but directly invading an adjacent organ, and the remaining patients had nodal or distant spread. The greatest majority of patients came from either Makkah or Riyadh. There were no provincial differences in the disease. There were more smaller and differentiated lesions in the sigmoid colon than in the rectum and right colon, but more patients with metastatic disease to the nodes or distant organs. Tumors were smaller at presentation and less disseminated in Saudis than in the other Arabs

management of anorectal abscess: an inexpensive and simple alternative technique to incision and deroofing

All patients with anorectal abscess who were referred to the University Department of Surgery in Wellington have been managed by simple "de Pezzer" drainage since 1981. The catheter used was between 3 to 5 mm in diameter and was usually inserted under a local anesthetic. The method is described in detail. One hundred and fifty-seven patients have presented with anorectal abscess, and after exclusion of those patients with intersphincteric abscess, 140 have been managed using de Pezzer drainage. The male to female ratio was 2.7:1. A perianal abscess was present in 120 patients. General anesthesia was necessary in 23 patients, and 20 of these patients were admitted to the hospital. Thirteen patients were admitted for underlying medical problems. Three patients had Crohn's disease and five were diabetics. Seventy-four of the patients had symptoms that had lasted for 4 days or less, and 40 patients had antibiotics prescribed by their local practitioners. There was no past history of anorectal sepsis in 104 patients. Ninety-four of the catheters were removed in less than 15 days. Of the patients who were drained under local anesthetic only, eight said that the pain was so "intolerable" that they would opt for a general anesthesia in the future. Fifty-three patients returned to their normal activities or work within five days, and 107 were back at work 14 days after drainage. Three abscesses were inadequately drained. Fistulae developed in 37 patients within the follow-up period. The technique appears to be safe and reliable, is well tolerated by patients, and results in minimal hospitalization and an early return to work