Botulinum Toxin Injection for Analgesic Effect after Hemorrhoidectomy: A Randomized Control Trial.

OBJECTIVES: Hemorrhoid is a common disease in surgical practice, but only a few numbers of patients need surgical treatment. The most common concern of patients is postoperative pain. This study aimed to evaluate the efficacy and safety of an intersphincteric injection of botulinum toxin for post-hemorrhoidectomy pain relief. METHODS: Overall, 90 patients were enrolled, and 44 were randomized into a botulinum toxin injection group. Preoperative gradings were grade III 37 patients and grade II 2 patients. Patients received an intersphincteric injection of 0.5 ml of a solution containing 30 units of botulinum toxin (BTX). The postoperative data were collected pain score in a visual analog score (VAS), an analgesic used, hospital stay, and complication. RESULTS: The VAS was lower in the BTX group at 12 hours and 24 hours postoperative phase. VAS at 12 hours 4.435 ± 2.149 vs 6.232 ± 2.307 (p < 0.001), VAS at 24 hours 2.205 ± 2.079 vs 3.744 ± 2.361(p = 0.003). The BTX group has a shorter time in defection without pain than the control group (3 vs. two days, p = 0.007). There was no difference in immediate and delay complications between the two groups. CONCLUSIONS: Postoperative hemorrhoidectomy needs multimodalities for pain reduction. Botulinum toxin has some benefit in postoperative pain reduction.

Bridging metallic stent placement in acute obstructed left sided malignant colorectal cancer: optimal time for surgery.

BACKGROUND: Colonic stenting is now the preferred treatment either for palliation or as a bridge to surgery for obstructed colorectal cancer. It reduces complications from emergency surgery and the need for colostomy formation. However, stent perforation can lead to peritoneal tumor spillage, a higher rate of infection and changing the risk of a potentially curable disease to an incurable one. Therefore, it is important to study the optimum time for operation after stent insertion. MATERIAL AND METHOD: From January 2006 to January 2012, 30 cases of acute left-sided malignant colorectal obstruction were managed by expandable metallic stent (SEMS) as a bridge to surgery. In all, 19 males and 11 females with mean age of 60.07±12.19 years (range 40-80 years) were included in the study. The obstructed locations were 1 case at the transverse colon, 6 cases at the descending colon, 13 cases at the sigmoid colon, 5 cases at the upper third at the rectum and 5 cases involving the middle third of the rectum. RESULTS: The perforation of SEMS was founded in 11 cases (36.67%). The mean bridging time before operation in the nonperforated group was 5.54 (±1.29) days shorter than in the perforated group, 10.54 (±4.82) days (p<0.001). All of the subjects in the perforated group reported clinical lower abdominal pain without sign of peritonitis, developed in an average 4.5 days (3-7 days). CONCLUSION: The optimum bridging time for surgery should be within 5 days.

Ligation of intersphincteric fistula tract and its modification: Results from treatment of complex fistula.

AIM: To compare healing rates between intersphincteric fistula tract (LIFT) and LIFT plus partial fistulectomy procedures. METHODS: A study of complex fistula-in-ano patients was carried out from 1(st) March 2010 to 31(th) January 2012. All operations were done by colorectal surgeons at a referral center in a Ministry of Public Health hospital. Data collected included patients' demographic details, fistula type determined by endorectal-ultrasonography, preoperative and postoperative continence status, previous operations, time between diagnosis of fistula-in-ano and operation, type of surgery, healing rates, recurrence rates, and types of failure examined by endorectal-ultrasosnography, re-operation in recurrence or failure cases, and complications. RESULTS: The study involved 41 patients whose average age was 40.78 ± 11.84 years (range: 21-71 years). The major fistula type was high-transsphincteric type fistula. The median follow-up period was 24 wk. The overall success rate was 83%: in the LIFT (Ligation intersphincteric fistula tract) group the success rate was 81% and in the LIFT plus (LIFT with partial coreout fistulectomy) group it was 85% (P = 0.529). The median wound-healing time was 4 wk in both groups (P = 0.262). The median time to recurrence was 12 wk. Neither group had incontinence (Wexner incontinence score-0) and the difference in healing rates between the two groups was not statistically significant. CONCLUSION: There was no difference in results between LIFT and LIFT plus operations. The LIFT procedure is a good option for maintaining continence in management of fistula-in-ano.

Single-access laparoscopic rectal surgery is technically feasible.

Introduction. Single-access laparoscopic surgery (SALS) has been successfully introduced for colectomy surgery; however, for mid to low rectum procedures such as total mesorectal excision, it can be technically complicated. In this study, we introduced a single-access technique for rectum cancer operations without the use of other instruments. Aims. To show the short-term results of single-access laparoscopic rectal surgery in terms of pathologic results and immediate complications. Settings and Design. Prospective study. Materials and Methods. We selected middle rectum to anal canal cancer patients to undergo single-access laparoscopic rectal resection for rectal cancer. All patients had total mesorectal excisions. An umbilical incision was made for the insertion of a single multichannel port, and a mesocolic window was created to identify the inferior mesenteric artery and vein. Total mesorectal excision was performed. There were no perioperative complications. The mean operative time was 269 minutes; the median hospital stay was 7 days; the mean wound size was 5.5 cm; the median number of harvested lymph nodes was 15; and all patients had intact mesorectal capsules. Statistical Analysis Used. Mean, minimum-maximum. Conclusion. Single-access laparoscopic surgery for rectal cancer is feasible while oncologic principles and patient safety are maintained.

Clinicopathological characteristics of mucinous and non-mucinous adenocarcinoma in the colon and rectum in Rajavithi Hospital, Thailand.

BACKGROUND: The clinicopathological characteristics of colorectal mucinous adenocarcinoma (MA) are still controversial. Most of the reports suggested that MA were associated with worse clinicopathological behavior and poorer prognosis than non-mucinous adenocarcinoma (NMA) while the others showed no difference. OBJECTIVE: To compare clinicopathological characteristics and tumor recurrence of MA patients with those in NMA patients. MATERIAL AND METHOD: During the period of 2000 to 2009 in Rajavithi Hospital, a total of 427 colorectal adenocarcinoma patient records consisting of 407 NMA and 20 MA were included in this study. Mean age, tumor location, TNM staging at diagnosis, T-stage, N-stage, preoperative CEA level and recurrent rate of MA patients were compared with those of NMA patients. RESULTS: The distribution of MA patients for gender, mean age, tumor location, TNM stage and preoperative CEA level were similar to those of NMA patients (all p > 0.05). Only the tumor recurrence in MA was significantly more common than that in NMA (p = 0.020, OR = 3.28 (1.14-9.43)), whereas the TNM stage was not significantly different from NMA (p = 0.530). The metastatic site and pattern of metastasis also showed no statistical significance (p = 0.125). CONCLUSION: The prognosis of MA is poorer than NMA. This may be associated with mucinous histological type itself.

Core out fistulectomy, anal sphincter reconstruction and primary repair of internal opening in the treatment of complex anal fistula.

OBJECTIVE: To determine the surgical technique "core out fistulectomy with anal sphincter reconstruction and primary closure of internal opening" in the treatment of trans-sphincteric fistula (high type or long tract) or supra-sphincteric fistula in terms of fistula healing, morbidity, recurrence and anal continence. MATERIAL AND METHOD: Between January 2004 and December 2005, 33 patients were enrolled in the present study. There were 30 males and 3 females with median age 42 (range 19-73) years. Most patients were high trans-sphincteric type (94%). The patients who had intersphincteric fistula, short tract trans-sphincteric fistula, fecal incontinence, or anal sphincter impairment were excluded. RESULTS: The median operative time was 35 (range 20-90) minutes. Median follow up was 14 (range 6-20) months. The median healing time was 4 weeks (range: 2 to 5 weeks) with minimal disturbance over patient life. There was one postoperative perianal hematoma treated by nonoperative mean and four cases of recurrent fistulas (cured by second operation) with no continence disturbance noted during the follow-up period. CONCLUSION: Core out fistulectomy with anal sphincter reconstruction and primary closure of internal opening is an effective procedure to be considered in the treatment of trans-sphincteric fistula (high type or long tract) with a satisfactory result while preserving both internal and external sphincters.

Preoperative capecitabine with pelvic radiotherapy for locally advanced rectal cancer (phase I trial).

OBJECTIVE: Phase I multicenter study defined the maximal tolerated dose (MTD), dose-limiting toxicity (DLT) and safety profile of capecitabine in combination with preoperative radiation for patients with locally advanced rectal cancer (LARC). MATERIAL AND METHOD: Patients were treated with oral capecitabine (700, 800, 900, 1000, 1100 and 1200 mg/m2 twice daily continuously) plus preoperative whole pelvic irradiation (45-46 Gy in 23-25 fractions over 5-6 weeks). Surgery was performed at the median of 42 days after chemoradiation treatment. RESULTS: Twenty-seven patients were in this trial. Eighteen patients (3 per dose level) had received capecitabine from 700 mg/m2 twice daily to the highest dose level of 1200 mg/m2 twice daily. There were no grade 3/4 DLTs during dose escalation, a further nine patients were included at the highest capecitabine dose. Two of the twelve patients (16%) receiving capecitabine 1200 mg/m2 twice daily developed grade 3 diarrhea and discontinued treatment. There were no other grade 3/4 adverse events. After capecitabine chemoradiation, 24 of 27 patients (89%) received definite surgery. Primary and lymph node down staging occurred in ten patients (42%). Sphincter-sparing surgery was performed in seven patients (26%) and abdominal-perineal resection was performed in 17 patients (63%). CONCLUSION: Preoperative capecitabine chemoradiation based on continuous daily capecitabine is very well tolerated in patients with LARC. The authors did not reach the MTD in the present study.