Higher symptom score, larger residual rectocele, and lower rectal compliance predict failure of improvement after surgical treatment of rectocele

Background: Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods: The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results: A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09-1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43-6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907-0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions: Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure. (AU)

End-to-end anal sphincter repair in treatment of post-traumatic fecal incontinence

The present report describes the end-to-end technique of anal sphincter repair in a 36-year-old female patient with post-vaginal delivery fecal incontinence (FI). The patient had a history of two vaginal deliveries and the symptoms of FI were observed after the second delivery. On assessment of the severity of FI using the Wexner incontinence score, the patient had a score of 12. Endoanal ultrasonography revealed an anterior defect of the external anal sphincter extending from 11 to 3 o'clock. The patient had no previous anal surgery and did not have any medical comorbidities. The operation time was 45minutes. No intraoperative complications were recorded. At 12 months of follow-up, the patient showed significant improvement in the continence state, with her Wexner score dropping to 4. No postoperative complications were recorded. We can conclude that end-to-end anal sphincter repair is a technically feasible operation that confers satisfactory improvement in the continence state without imposing much tension on the site of sphincter repair. (AU)

Evidence-based review of methods used to reduce pain after excisional hemorrhoidectomy / Revisão baseada em evidências de métodos utilizados para reduzir a dor após hemorrroidectomia excisional

ABSTRACT Background: Excisional hemorrhoidectomy is one of the most commonly performed anorectal procedures. Despite the satisfactory outcomes of excisional hemorrhoidectomy, the pain perceived by the patients following the procedure can be a distressing sequel. This review aimed to search the current literature for the existing evidence on how to avoid or minimize the severity of post-hemorrhoidectomy pain. Methods: An organized literature search was performed using electronic databases including PubMed/Medline and Google Scholar service for the articles that evaluated different methods for pain relief after excisional hemorrhoidectomy. Then, the studies were summarized in a narrative way illustrating the hypothesis and the outcomes of each study. The methods devised to reduce pain after excisional hemorrhoidectomy were classified into three main categories: technical tips; systemic and topical agents; and surgical methods. The efficacy of each method was highlighted along the level of evidence supporting it. Results: Stronger evidence (level Ia) supported LigaSure hemorrhoidectomy and the use of glyceryl trinitrate ointment to be associated with significant pain relief after excisional hemorrhoidectomy whereas the remaining methods were supported by lower level of evidence (level Ib). Conclusion: The use of LigaSure in performing excisional hemorrhoidectomy and the application of topical glyceryl trinitrate ointment contributed to remarkable relief of postoperative pain after excisional hemorrhoidectomy according to the highest level of evidence. Perhaps a multimodality strategy that combines systemic and topical agents can be the optimal method for control of pain after excisional hemorrhoidectomy, yet further prospective trials are required to draw such conclusion.

RESUMO Introdução: A hemorroidectomia excisional (HE) é um dos procedimentos anorretais mais comumente realizados. Apesar dos resultados satisfatórios da hemorroidectomia excisional, a dor percebida pelos pacientes após o procedimento pode ser uma sequela angustiante. Esta revisão teve como objetivo buscar na literatura atual as evidências existentes sobre como evitar ou minimizar a gravidade da dor pós-hemorroidectomia. Métodos: Uma busca organizada da literatura foi realizada usando bancos de dados eletrônicos, incluindo PubMed/Medline e Google Scholar, para os artigos que avaliaram diferentes métodos para o alívio da dor após hemorroidectomia excisional. Em seguida, os estudos foram resumidos de forma narrativa, ilustrando a hipótese e os resultados de cada estudo. Os métodos desenvolvidos para reduzir a dor após a hemorroidectomia excisional foram classificados em três categorias principais: dicas técnicas; agentes sísticos e ticos; e métodos cirúrgicos. A eficácia de cada método foi destacada ao longo do nível de evidência que a suporta. Resultados: Evidências mais fortes (nível Ia) apoiaram a hemorroidectomia de LigaSure e o uso de pomada de trinitrato de glicerila para ser associado com alívio significativo da dor após hemorroidectomia excisional, enquanto os métodos restantes foram apoiados por menor nível de evidência (nível Ib). Conclusão: O uso de LigaSure na realização de hemorroidectomia excisional e a aplicação de pomada tópica de gliceril trinitrato contribuíram para o notável alívio da dor pós-operatória após hemorroidectomia excisional, de acordo com o maior nível de evidência. Talvez uma estratégia multimodal que combine agentes sistêmicos e tópicos possa ser o método ideal para o controle da dor após hemorroidectomia excisional, mas ainda são necessários mais estudos prospectivos para chegar a essa conclusão.

Gender-based analysis of the characteristics and outcomes of surgery for anal fistula: analysis of more than 560 cases / Análise baseada no sexo das características e desfechos de cirurgia para fístula anal: análise de mais de 560 casos

ABSTRACT Background: Fistula-in-ano commonly affects males more than females. Some differences in the characteristics of fistula-in-ano between both genders have been recognized, yet the impact of these differences on the outcomes of surgery for fistula-in-ano is still unclear. The present study conducted a gender-specific analysis aiming to assess the characteristics and the outcomes of surgery of fistula-in-ano in each gender. Patients and methods: The records of patients with fistula-in-ano were retrospectively reviewed and the following variables were extracted: patients' demographics, type of fistula-in-ano, position of the external opening, operation performed, incidence of recurrence and complications, particularly fecal incontinence. Gender-based analysis of the characters and outcomes of surgery for fistula-in-ano was performed. Results: 565 (491 males) patients of a mean age of 41.7 years were included. Females had a significantly higher percentage of low fistula-in-ano than males (70.2% vs. 50.3%, p = 0.002). Males had a significantly higher percentage of high trans-sphincteric fistula-in-ano (48.5% vs. 29.7%; p = 0.003). Anterior fistula-in-ano was more common in female patients (69% vs. 16.3%; p < 0.0001). Recurrence of fistula-in-ano was detected in 42 (7.4%) patients. Males had higher recurrence rate than females (7.9% vs. 4%; p = 0.34). Fecal incontinence developed in 1.7% of patients with higher incidence observed in females (4% vs. 1.4%). Conclusion: The majority of fistula-in-ano in males were posterior and high trans-sphincteric whereas most fistula-in-ano in females were low and anteriorly based. Despite the different characteristics of fistula-in-ano; no significant differences in the rates of fistula recurrence and fecal incontinence between males and females could be recorded.

RESUMO Background: A fístula anal comumente acomete mais os homens que as mulheres. Algumas diferenças nas características da fístula anal entre ambos os sexos têm sido reconhecidas, embora o impacto dessas diferenças nos desfechos da cirurgia para fístula anal ainda seja incerto. O presente estudo realizou uma análise específica para sexo, com o objetivo de avaliar as características e os desfechos da cirurgia de fístula anal em cada sexo. Pacientes e métodos: Os prontuários de pacientes com fístula anal foram revisados retrospectivamente e as seguintes variáveis foram extraídas: dados demográficos dos pacientes, tipo de fístula anal, posição da abertura externa, cirurgia realizada, incidência de recidiva e complicações, particularmente incontinência fecal. Realizou-se uma análise baseada no sexo dos sujeitos e desfechos da cirurgia para fístula anal. Resultados: Foram incluídos 565 pacientes (491 do sexo masculino) com idade média de 41,7 anos. As mulheres apresentaram uma porcentagem significativamente mais alta de fístula anal baixa do que os homens (70,2% vs. 50,3%, p = 0,002). Os homens tiveram uma porcentagem significativamente maior de fístula anal transesfincteriana alta (48,5% vs. 29,7%; p = 0,003). A fístula anal anterior foi mais comum em pacientes do sexo feminino (69% vs. 16,3%; p < 0,0001). A recorrência de fístula anal foi detectada em 42 (7,4%) pacientes. Os homens apresentaram maior taxa de recorrência do que as mulheres (7,9% vs. 4%; p = 0,34). A incontinência fecal desenvolveu-se em 1,7% dos pacientes com maior incidência observada no sexo feminino (4% vs. 1,4%). Conclusão: A maioria das fístulas anais no sexo masculino foi posterior e transesfincteriana alta, enquanto a maioria das fístulas anais no sexo feminino foi baixa e anterior. Apesar das diferentes características da fístula anal, não foi possível registrar diferenças significativas nas taxas de recorrência de fístula e incontinência fecal entre homens e mulheres.