The effect of anorectal manometric examination on the surgical treatment plan in chronic anal fissure.

INTRODUCTION: Although lateral internal sphincterotomy (LIS) is the most preferred surgical treatment for chronic anal fissure, In this study, we aimed to investigate the effect of preoperative anorectal manometry on surgical treatment choice in patients presenting with anal fissure. MATERIAL AND METHODS: Between January-2015 and August-2017 and whose physical examination revealed chronic anal fissure findings were included in the study. Patients were divided into two groups as Group 1 LIS and Group 2 non-LIS. In addition to the demographic characteristics of the patients, anal manometry findings and its effect on surgical treatment options were examined. RESULTS: 20 patients (M/F:13/7) were included in the study. The mean age was 48.3+17.4 in Group 1 and 45.25 +24.45 in Group 2 (p:0.797). In the preoperative manometric examination, resting pressure(mmHg) range was 93.2+15.9 in Group 1, and44+11.2 in Group 2 (30-57) (p:0.001). Endurance to squeezing time was shorter in Group 2 (p:0.0138). There were no differences between the groups in terms of mean squeezing pressure, rectal sensation, and rectoanal inhibitor reflex (p>0.05). Of the four patients with low sphincter pressures, 3 underwent botulinum toxin injection and 1 underwent advancement flap instead of LIS. There was no significant difference between preoperative and postoperative CCFI scores in the LIS group (0.6±1.8 vs. 1.2±1.85, p>0.05). CONCLUSION: In the treatment of chronic anal fissure, non-LIS methods were selected in 20% of the patients with the help of preoperative anal manometric examination. Manometric examination is important to minimize the risk of incontinence and to determine the choice of treatment correctly. KEY WORDS: Anal fissure, Anal incontinence, Anal manometry.

A qualitative and quantitative assessment of simultaneous strain, shear wave, and point shear wave elastography to distinguish malignant and benign breast lesions.

BACKGROUND: Ultrasound (US) elastography has become a routine instrument in ultrasonographic diagnosis that measures the consistency and stiffness of tissues. PURPOSE: To distinguish benign and malignant breast masses using a single US system by comparing the diagnostic parameters of three kinds of breast elastography simultaneously added to B-mode ultrasonography. MATERIAL AND METHODS: A total of 163 breast lesions in 159 consecutive women who underwent US-guided core needle biopsy were included in this prospective study. Before the biopsy, the lesions were examined with B-mode ultrasonography and strain (SE), shear wave (SWE), and point shear wave (STQ) elastography. The strain ratio was computed and the Tsukuba score determined. The mean elasticity values using SWE and STQ were computed and converted to Young's modulus E (kPa). RESULTS: All SE, SWE, and STQ parameters showed similar diagnostic performance. The SE score, SE ratio, SWEmean, SWEmax, STQmean, and STQmax yielded higher specificity than B-mode US alone to differentiate benign and malignant masses. The sensitivity of B-mode US, SWE, and STQ was slightly higher than that of the SE score and SE ratio. The SE score, SE ratio, SWEmean, SWEmax, STQmean, and STQmax had significantly higher positive predictive value and diagnostic accuracy than B-mode US alone. The area under the curve for each of these elastography methods in differentiating benign and malignant breast lesions was 0.93, 0.93, 0.98, 0.97, 0.98, and 0.96, respectively; P<0.001 for all measurements. CONCLUSION: SE (ratio and score), SWE, and STQ had higher diagnostic performance individually than B-mode US alone in distinguishing between malignant and benign breast masses.

The importance of anorectal physiology tests in clinical diagnosis and treatment.

AIM: In this study, we aimed to convert subjective findings to objective findings and to determine the effect of anorectal physiology tests on the diagnosis and treatment of patients with defecatory complaints. MATERIAL AND METHOD: Two hundred and forty patients who applied to the proctology unit between January 2015 and August 2017 were included in our study. The patients were divided into 3 groups based on their presentation complaints; Group 1: Obstructive defecation syndrome(ODS), Group 2: Peroperative except anal incontinence and control after sphincter repair, Group 3: Anal incontinence.Group 2 and Group 3 were divided into subgroups. The demographic data of the patients were retrospectively analyzed. The number of anorectal physiological tests in groups and the rates of referral to surgical or medical treatment were evaluated. FINDINGS: Two hundred and forty patients were included in our study. The highest mean age was in Group 3 (46.2±17.8) (p: 0.356) 43.3% of the patients in our study were female. Anorectal manometry was performed in all patients. Endoanal USG was most commonly performed in Group 2 (42.6%, p:0.013), defecography in Group 1 (47.4%, p: 0.0001), and EMG in Group 3(25.3%, p: 0,001). In Group 1, 33% of the patients with pathological defecography findings had surgical treatment (p<0.05). In Group 2a, the rate of surgical treatment was higher in patients who underwent anal USG with anorectal manometry (%25.6vs %40). In Group 3, the rate of surgical treatment was higher in patients who underwent anal ultrasound with manometry (%1.9 vs %32.6 p<0.005) DISCUSSION: Anorectal physiological tests are important for accurate diagnosis and treatment planning. The combined use of anorectal physiological tests in anal incontinence groups increased the rate of referral to surgical treatment.

Short-term results of adipose-derived stem cell therapy for the treatment of complex perianal fistula A single center experience.

BACKGROUND: In this study, we aimed to investigate the early results of the safety and efficacy of adipose-derived stem cells (ADSCs) injection along with the repair of the internal orifice in the recovery of complex perianal fistula. METHODS: The study included patients who underwent autologous adipose tissue-derived stemcell injection for complex perianal fistula between December2017 and January2018. The FDA-approved Lipogems® system was used to prepare autologous micro-fragmented adipose stem cells. Demographic characteristics, history of inflammatory bowel disease, fistula type and length of fistula tract determined by endoanal ultrasound, mean operation duration, postoperative complications, and fistula healing of the patients were evaluated. Fistula healing was evaluated on the 30th ,90th days and 9th months. RESULTS: A total of 10 patients, with male predominance, were included in our study. The mean age was 47±13.1 and mean BMI was 28.3±4.79. None of the patients had inflammatory bowel disease Based on endoanal ultrasound findings, fistula type was transsphincteric, extrasphincteric and suprasphincteric for 7, 2 and 1 patients, respectively. Calculated length of fistula tract based on ultrasound was 4.45±1.69(2.5-6.4). Mean duration of operation was 45±7 minutes. None of the patients had any treatment related toxicity, however, two patients experienced bruising at the liposuction site. Healing rate in the follow-up of 30-day, 90-day and 9-month was 70%, 80% and 70%, respectively. CONCLUSIONS: In addition to surgical treatment in the form of curettage and closure of the fistula tract, autologous micro-fragmented adipose tissue injection is a safe, feasible, and reproducible procedure that can be performed based on the early results in complex anal fistula healing. KEY WORDS: Lipogems®, Mesenchymal stem cell, Regenerative medicine, Adipose tissue-derived mesenchymal stem cell.

Comparison of Diverting Colostomy and Bowel Management Catheter Applications in Fournier Gangrene Cases Requiring Fecal Diversion.

In some patients of Fournier gangrene originated from perianal region, it is important to prevent fecal contamination in order to provide healing without wound infection. For this purposes, diverting colostomy or bowel management catheter methods were performed. In this study, it is aimed to carry out a comparison of prognosis and cost efficiency between diverting colostomy and bowel management catheter methods applied for preventing fecal contamination in Fournier's gangrene patients. Fourty-eight patients with diagnosis of Fournier's gangrene, serious perianal infections, and preserved sphincters and without rectum injury after debridement were included in the study. The cases were divided into two groups as patients who were subjected to colostomy for fecal diversion and who were subjected to bowel management catheter without colostomy. Then, the groups were compared in terms of age, predisposing factors, duration of hospital stay, mortality, additional surgery requirements, and cost. Fourty-eight patients were included the study. Sixteen patients were treated without colostomy. Decreased duration of total hospital stay, additional surgery requirements, and hospital expense in bowel management catheter group has determined. It is thought that preferring bowel management catheter method instead of colostomy in patients without rectum injury, who require diverting colostomy and have undamaged anal sphincters, can relieve patients, patients' relatives, healthcare organizations, and the national economy of a serious burden. In addition, although patients' satisfaction and workforce loss factors are not taken into consideration in this study, the bowel management catheter method is thought to have positive effects also on these parameters.

Isolated hepatic tuberculosis presenting as cystic-like and tumour-like mass lesions.

Hepatic tuberculosis is a rare manifestation of extra-pulmonary tuberculosis. Hepatic tuberculous lesions are especially mimicking tumour-like mass or cystic lesions in the liver and so can be misdiagnosed with several diseases. Histopathological examination of the specimen is essential in the diagnosis for hepatic tuberculosis. In this report, two cases with hepatic tuberculosis having cystic solid mass and abscess liver lesions are described.

A new seton type for the treatment of anal fistula.

In this retrospective study, our aim was to introduce an industrial synthetic material that can be used as a seton and then to present the results of complicated anal fistula cases treated with this different sort of seton. Between 1997 and 2005, 32 patients (aged 27-63 years) with a high anal or rectal internal opening were treated with a cutting seton. In the postoperative period none of the patients had recurrence or solid stool incontinence. However, three of them had just flatus incontinence, and two had flatus and liquid stool incontinence. The new material we used as a new type of seton can be used efficiently; it can be inserted easily, is cheap and effective, and may give better therapeutic results and better patient satisfaction.