Modified Martius graft - a renaissance of surgical procedure.

AIM: The rectovaginal fistula (RVF) is relatively uncommon and by clinical manifestations grave illness. The surgery treatment of RVF is extremely demanding and represents the subject of frustration for many surgeons. Miscellaneous etiology of RVF and various heights of fistula in a rectovaginal septum are crucial for the choice of surgical procedure. Despite targeted treatment, more than one-half of rectovaginal fistulas recurs. We evaluated the frequency of recurrences after surgical treatment by modified Martius graft and its influence on continence and quality of life. The necessity of concomitant colostomy when performing modified Martius graft was the secondary aim. METHOD: We collected and analyzed 8 years of data from our patient database. There were admitted 21 female patients with diagnosis RVF to the Surgery department of Faculty Hospital Trnava. Unfortunately, only 5 patients, concerning the etiology of disease and clinical state, were indicated for surgery by modified Martius graft. All RVFs were low and a defect in the rectovaginal septum wouldn't exceed 1.5 cm in diameter. RESULTS: Due to the small sample and non-confirmation of normality in all variables, nonparametric comparison tests were chosen for paired samples differences. We used the Wilcoxon sign-rank test and counted the effect sizes expressed the success of the treatment. Each female patient with low RVF included in this study has healed. The mean value of a complete healing of RVF in our cohort was 12 weeks. We had discovered one recurrence after surgery, that was successfully repaired by contralateral modified Martius graft. The significant decrease of Wexner fecal incontinence score in the observed group (p<0.05, r=0.639) and slightly elevated Cleveland Clinic Constipation Scoring System (p<0.05, r=-0.577) were confirmed. The protective colostomy was performed just once. Only two sections of the SF-36 Health Survey - the physical functioning and the bodily pain, were without significant changes. The rest of the watching sections of SF-36 have changed significantly. CONCLUSION: Treatment of low rectovaginal fistulas (LRVF) by modified Martius graft is followed by a low percentage of recurrences. It should be the first-line therapy in the algorithm of surgical treatment of LRVF, without the necessity of protective colostomy (Tab. 2, Fig. 3, Ref. 27).

Endoscopic pyloromyotomy for the treatment of severe and refractory gastroparesis: a pilot, randomised, sham-controlled trial.

OBJECTIVE: Endoscopic pyloromyotomy (G-POEM) is a minimally invasive treatment option with promising uncontrolled outcome results in patients with gastroparesis. DESIGN: In this prospective randomised trial, we compared G-POEM with a sham procedure in patients with severe gastroparesis. The primary outcome was the proportion of patients with treatment success (defined as a decrease in the Gastroparesis Cardinal Symptom Index (GCSI) by at least 50%) at 6 months. Patients randomised to the sham group with persistent symptoms were offered cross-over G-POEM. RESULTS: The enrolment was stopped after the interim analysis by the Data and Safety Monitoring Board prior to reaching the planned sample of 86 patients. A total of 41 patients (17 diabetic, 13 postsurgical, 11 idiopathic; 46% male) were randomised (21 G-POEM, 20-sham). Treatment success rate was 71% (95% CI 50 to 86) after G-POEM versus 22% (8-47) after sham (p=0.005). Treatment success in patients with diabetic, postsurgical and idiopathic gastroparesis was 89% (95% CI 56 to 98), 50% (18-82) and 67% (30-90) after G-POEM; the corresponding rates in the sham group were 17% (3-57), 29% (7-67) and 20% (3-67).Median gastric retention at 4 hours decreased from 22% (95% CI 17 to 31) to 12% (5-22) after G-POEM and did not change after sham: 26% (18-39) versus 24% (11-35). Twelve patients crossed over to G-POEM with 9 of them (75%) achieving treatment success. CONCLUSION: In severe gastroparesis, G-POEM is superior to a sham procedure for improving both symptoms and gastric emptying 6 months after the procedure. These results are not entirely conclusive in patients with idiopathic and postsurgical aetiologies. TRIAL REGISTRATION NUMBER: NCT03356067; ClinicalTrials.gov.

Stenting to prevent esophageal stricture after circumferential endoscopic submucosal dissection: an experimental study.

Background and study aims Circular ESD (CESD) is a treatment option for patients with extensive early esophageal cancer. Its major drawback is the development of a stricture. Stenting may represent an attractive prevention strategy. We designed an experimental study to assess the effect of stents covered with acellular biomatrix (AB) and a drug-eluting stent. Materials and methods Thirty-five 35 pigs underwent CESD and were randomized into six groups: G1 (control), G2 (SEMS), G3 (SEMS + AB), G4 (SEMS + AB + steroid-eluting layer), G5 (biodegradable stent [BD]), G6 (BD + AB). SEMS were placed alongside the post-CESD defect, fixed and removed after 21 days. The main outcomes were stricture development, severity, and histopathology. Results Pigs with BD stents (G5, 6) experienced severe inflammation and hypergranulation without biodegradation, therefore, these groups were closed prematurely. Significant strictures developed in 29 of 30 pigs (96.7 %). The most severe stricture developed in G2 and G4 (narrowest diameter (mm) 8.5 ±â€Š3, 3 (G2) and 8.6 ±â€Š2.1 (G4) vs. 17 ±â€Š7.3 (G1) and 13.5 ±â€Š8.3 (G3); P  < 0.01. Signs of re-epithelization were present in 67 % and 71 % in G1 and G2 and in 100 % in G3 and G4. The most robust re-epithelization layer was present in G4. The inflammation was the most severe in G1 (mean score 2.3) and least severe in G4 (0.4). Conclusions Stenting did not effectively prevent development of post-CESD esophageal stricture. SEMS with AB resulted in improved re-epithelization and decreased stricture severity. Steroid-eluting SEMS suppressed inflammation. BD stents seem inappropriate for this indication.

Redefining the alanine aminotransferase upper limit of normal improves the prediction of metabolic syndrome risk.

BACKGROUND: Multiple studies have recently proposed the lowering of upper limit of normal (ULN) for alanine aminotransferase (ALT) to improve the diagnostic sensitivity for viral hepatitides and metabolic syndrome (MS). We have tried to validate some of the proposed ULNs in the diagnosis of MS. METHODS: We used data from the HepaMeta Study conducted in 2011 in Slovakia, which explored the prevalence of MS in eastern Slovakia. Patients were tested for the criteria of MS and ALT. Different, previously published, ALT cutoffs were then used to calculate odds' ratios, sensitivity, specificity, and accuracy of MS and its components. RESULTS: Manufacturers' recommended ULN used in our institution (0.8 µkat/l, 47 U/l for men and 0.6 µkat/l, 35 U/l for women) failed to predict any significant risk of MS. Lowered cutoff (72% of the original ULN) identified the patients with the highest age-adjusted probability of MS (odds ratio 3.194, 95% confidence interval 1.398-7.295). ALT was significantly associated with elevated levels of triacylglycerols, hyperglycemia, and obesity. CONCLUSION: In patients with MS, one must consider liver involvement if the patient has ALT levels in the upper third of the reference range. There is the need for discussion about the feasibility of lower ALT ULN in clinical practice.