Stapled transanal rectal resection: a new surgical treatment for obstructed defecation syndrome.

BACKGROUND: Rectal intussusception, rectocele and rectal prolapse are anatomic disorders in obstructed defecation syndrome. A relatively new surgical approach, Stapled Transanal Rectal Resection, was designed to treat these anomalies. OBJECTIVES: To present our preliminary results with this technique. METHODS: Thirty patients with ODS not responding to medical treatment or biofeedback were operated on with the STARR technique. All the patients underwent a complete workup in the Pelvic Floor Unit. The operation was performed according to the technique described elsewhere. RESULTS: The patients' mean age was 67.1 years, and the median duration of symptoms was 7 years. The mean operating time was 40 minutes (range 35-80 min) and the mean hospital stay was 2 days (range 1-4 days). The mean follow-up was 26 months (range 6-48 months). ODS symptoms were ameliorated in 27 patients (90%), decreased significantly in 18, and in 9 patients the symptoms disappeared. The procedure failed in 3 patients (10%). Complications included minor bleeding that required homeostasis in eight patients during the operation. Three patients had transient tenesmus and five patients had anal pain. There were no cases of mortality or pelvic sepsis. CONCLUSIONS: STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception, rectocele and small rectal prolapse.

Resting anal pressure following hemorrhoidectomy and lateral sphincterotomy.

PURPOSE: The role of high anal pressure in the pathophysiology of hemorrhoids and anal fissures is debated. We compared resting anal pressures following left lateral sphincterotomy and hemorrhoidectomy in a prospective manometric study with emphasis on the recovery of the internal anal sphincter activity. METHODS: Included in the study were 38 patients with third-degree or fourth-degree symptomatic hemorrhoids who underwent hemorrhoidectomy, 50 patients with anal fissure who underwent sphincterotomy, and 12 healthy patients who served as controls. All patients with anal fissure or hemorrhoids underwent periodic manometric evaluation: 1 month before surgery and 1, 3, 6, and 12 months after surgery. The control group had three manometric evaluations 6 months apart. RESULTS: Baseline pressure measurement in the fissure group was significantly higher than in the hemorrhoid group, which was significantly higher than in the control group (138 +/- 28.4 mmHg vs. 108.4 +/- 23 mmHg vs. 73 +/- 5.9 mmHg, P < 0.0001). Twelve months after surgery, anal resting pressure remained significantly lower than the baseline measurements in both the fissure (110 +/- 18.2 vs. 138 +/- 28.4, P < 0.0001) and hemorrhoid groups (103.6 +/- 21.5 vs. 108 +/- 23, P < 0.0001), but both remained higher than the control group (103.6 +/- 21.5 mmHg vs. 73 +/- 5.9 mmHg, P < 0.0001). CONCLUSIONS: Resting pressure is elevated in hemorrhoid and anal fissure patients. After surgery the anal resting pressure is reduced but is still higher than in the control group. Further studies are required to investigate the protective effect of postsurgical reduction of anal resting pressure against recurrence.

Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study.

BACKGROUND: Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy. OBJECTIVE: The aim of this study was to evaluate long-term manometric results of sphincter healing following lateral internal sphincterotomy. PATIENTS AND METHODS: Between 2000 and 2003, 50 patients with anal fissure were included in this study and underwent sphincterotomy; 12 healthy patients served as controls. All patients with anal fissure underwent manometric evaluation using a 6-channel perfusion catheter. All patients were examined 1 month before surgery and 1, 3, 6, and 12 months following surgery. The control group had 3 manometric evaluations 6 months apart. RESULTS: The mean basal resting pressure before surgery was 138 +/- 28 mm Hg. One month after surgery, the pressure dropped to 86 +/- 15 mm Hg (P < 0.0001) and gradually rose to a plateau at 12 months (110 +/- 18 mm Hg, P < 0.0001). At 12 months, the manometric pressure was significantly lower than the baseline (P < 0.0001). However, manometric measurements in the fissure group were still significantly higher than in the control group (110 +/- 18 versus 73 +/- 4.8 mm Hg, P < 0.0001). All patients were free of symptoms at the 12-month follow-up. CONCLUSION: Lateral internal sphincterotomy caused a significant decline in the resting anal pressure. During the first year following surgery, the tone of the internal anal sphincter gradually increased, indicating recovery, but still remained significantly lower than before surgery. However, postoperative resting pressures were higher than those in the control, and no patient suffered any permanent problems with incontinence, so this decrease may not be clinically significant.

Long-term follow-up and factors influencing success of silastic ring vertical gastroplasty.

BACKGROUND: Careful selection of patients for the operation plays a major role in long-term results of silastic ring vertical gastroplasty. The objective of the current study is to identify predictive factors for the objective (excess weight loss) and subjective (satisfaction) success of silastic ring vertical gastroplasty (SRVG) for morbid obesity. DESIGN: Retrospective cohort study. SETTING: University hospital. SUBJECTS: 300 patients of 450 who were operated on between 1984 and 1997. Follow-up time was 4.4 +/- 2.3 years. INTERVENTION: SRVG. STATISTICAL METHODS: Correlations, multi-linear regression model. RESULTS: Average BMI (body mass index) loss: 13.6 +/- 7.4 kg/m(2), average excess weight loss was 67.4 +/- 33.0%. Satisfaction rate: 81.3%. Correlation was found between objective parameters of successes and the satisfaction of the patient (p < 0.001). Excess weight loss was correlated to younger age (p < 0.005), pre-operative weight and BMI (p < 0.005, p < 0.01, respectively), and shorter follow-up (p < 0.001). Multiple linear regression model revealed that age and preoperative weight were independent variables and correlated to the excess weight loss after SRVG (R(2) = 0.303, p < 0.01; R(2) = 0.026, p < 0.05). Social support was correlated to satisfaction (p < 0.05). CONCLUSIONS: SRVG is an operation with high rates of objective and subjective success rate. Younger and heavier subjects will mostly enjoy SRVG in terms of excess weight loss. Patients who have social support have the most satisfactory emotional outcome.