New objective scoring system to clinically assess fecal incontinence.

BACKGROUND: Several scoring systems are used to assess fecal incontinence (FI), among which, the most commonly used are Wexner and Vaizey's scoring systems. However, there are significant lacunae in these scoring systems, due to which they are neither accurate nor comprehensive. AIM: To develop a new scoring system for FI that is accurate, comprehensive, and easy to use. METHODS: A pro forma was made in which six types of FI were included: solid, liquid, flatus, mucous, stress, and urge. The weight for each FI was determined by asking a group of patients and laypersons to give a disability score to each type of FI from 0 to 100 (0- least, 100- maximum disability). The disability was assessed on a modified EQ-5D+ (EuroQol) description system, 4D3L (4 dimensions and 3 levels) for each FI. The average score of each FI was calculated, divided by 10, and rounded off to determine the weight of each FI type. The scores for the three levels of frequency of each FI were assigned as never = 0 (No episode of FI ever), occasional = 1 (≤ 1 episode of FI/ wk), and common = 2 (> 1 episode of FI/ wk), and was termed as frequency score. The score for each FI would be derived by multiplying the frequency score and the weight for that FI type. In the second phase of the study, a group of colorectal surgeons was asked to rank the six FI types in order of severity, and their ranking was compared with the patient and laypersons' rankings. RESULTS: Fifty patients and 50 laypersons participated in the study. The weight was assigned to each FI (solid-8, liquid-8, urge-7, flatus-6, mucus-6, and stress-5), and an new scoring system was formulated. The maximum possible score was 80 (total incontinence), and the least 0 (no incontinence). The surgeons' ranking of FI severity did not correlate well with patients' and laypersons' rankings of FI, highlighting that surgeons and patients may perceive the severity of FI differently. CONCLUSION: A new scoring system for FI was formulated, which was simple, logical, comprehensive, and easy to use, and eliminated previous shortcomings. Patients' and surgeons' perceptions of FI severity of FI did not correlate well.

Results of surgical treatment of pilonidal sinus in 50 patients operated using Bascom II procedure - prospective study.

INTRODUCTION: Treatment of the pilonidal sinus, due to various surgical methods, remains the current topic of discussion during surgeon meetings worldwide. The newest methods of treatment consist in the excision and simultaneous closure of the wound with cleft lift procedures. One of such methods is Bascom II procedure which has been widely used in the world but is less popular in Poland. AIM OF THE STUDY: To evaluate the results of treatment of pilonidal cysts using Bascom II procedure performed by one operator. MATERIAL AND METHOD: 50 patients (40 men, 10 women), Avg. 30.6 years of age. All patients treated with Bascom II procedure in one surgical ward by one operator (resident during specialisation training) with the use of uniform surgical care for all operational protocols. The following were assessed: BMI, average hospitalisation time, pain, post-operative complications, wound healing time, patient's quality of life, and the recurrences rate after surgery. The follow-up period ranged from 12 to 52 months. RESULTS: Average BMI 27.13 kg / m2. Avg. time of hospitalisation 2.95 days. Post-operative pain in the first 24 hours was on average 4.55 points. (+/- 2.24 points); on the 10th day on average 2.04 points (+/- 1.58 points); in the 30th day on average 0.76 points (+/- 1.1 points). Pain after healing 0.14 points (+/- 0.40 points). Post-oerative complications occurred in 28.57% of patients [partial wound dehiscence (16.32%), serum leak (10.2%), hematoma (6.12%), total wound dehiscence (0%), wound infection (0%)]. The average time of full healing was 2.94 weeks. Recurrence occurred in one patient (2.04%). CONCLUSIONS: Bascom II procedure is characterised by a low recurrence rate and short wound healing time. It is a a safe, effective and patient-accepted method of treatment. Statistically, it significantly improves the patient's quality of life one year after surgery in terms of both physical and mental health.

A novel template for anorectal fistula reporting in anal endosonography and MRI - a practical concept.

Anorectal fistula surgery is associated with risks of recurrence and/or faecal incontinence due to anal sphincter injuries. In order to minimise these complications, preoperative evaluation of the anatomy of the fistula tract and morphology of the anal sphincters is mandatory. Anal endosonography (AES) and Magnetic Resonance Imaging (MRI), due to high resolution of images and ability to identify a number of fistula elements which are important for surgeons in treatment planning, are the methods of choice in the diagnosis of anorectal fistulas.In this paper, a new template for endosonographic and MRI report, systematically describing all anorectal fistula's characteristics, is presented. This template provides practical information for the surgeon, useful in preoperative assessment and postoperative follow-up.

New porcine model of perineal tear and its utility in physicians' training on the reconstruction of 3rd and 4th degree perineal tear during vaginal delivery.

OBJECTIVES: One of the most serious complications of vaginal delivery is 3rd and 4th degree perineal tear and its incorrect management results in anal incontinence. Animal-based anatomical models of childbirth-induced perineal tear are an important element of the physicians' practical training [1]. The proposed new model, prepared using porcine tongue and intestine, closely mimics all the tissues and organs subjected to injury during complicated deliveries and constitutes an educational opportunity for the reconstruction of the injuries. The objective of this paper was to present a new porcine model of the perineum and to evaluate the utility of this model in the training of physicians on the reconstruction of the 3rd and 4th degree perineal tear during childbirth. MATERIAL AND METHODS: We presented a preparation method of the proposed model and a calculation of the amount of time and costs required for its preparation. The utility of the model was assessed using a questionnaire completed by the participants of a workshop conducted with the model. RESULTS: We found that 95% of the respondents had never practiced perineal reconstruction on any model. According to 85% of the respondents, our model was very similar to natural tissues. According to 95% of the respondents, the simulated model of the perineal tear satisfactorily mimicked the real-life situation. CONCLUSIONS: The presented model is cheap and easy to prepare. It satisfactorily mimics the tissues and tissue injuries caused by the tear, making it helpful in training physicians on the reconstruction of 3rd and 4th degree perineal tear.

Anorectal malformation as a cause of recurring perineal abscesses - value of anorectal endosonography and magnetic resonance imaging: a case report.

Malformations of the rectum and urinary tract frequently coexist, and the prevalence of urogenital defects in patients with a rectal defect ranges from 20 to 54%. In most patients, anorectal malformations are diagnosed and treated surgically in early childhood. In this report, we present a case of a 52-year-old male with a history of urological operations in infancy due to a congenital urethral malformation and multiple recurrent episodes of perineal abscesses with urinary retention. Anorectal endosonography and magnetic resonance imaging revealed the presence of a large cystic lesion adjacent to the rectal wall which became smaller at the level of the puborectalis. The walls of the lesion had a layered structure identical to the wall of the rectum. In addition, the examinations showed hypotrophy of the left lobe of the prostate and lack of left semnal vesicles. Thus, the lesion was diagnosed as duplication of the rectum or rectal diverticulum. Surgery was performed by an interdisciplinary team of colorectal surgeons and urologist. The lesion was removed laparoscopically. The pathological report revealed that the cystic wall was typical of the intestinal wall, consistent with a diagnosis of rectal duplication.

Magnetic resonance imaging and endorectal ultrasound for diagnosis of rectal lesions.

Endorectal ultrasonography (ERUS) and magnetic resonance imaging (MRI) allow exploring the morphology of the rectum in detail. Use of such data, especially assessment of the rectal wall, is an important tool for ascertaining the perianal fistula localization as well as stage of the cancer and planning it appropriate treatment, as stage T3 tumors are usually treated with neoadjuvant therapy, whereas T2 tumors are initially managed surgically. The only advantage of ERUS over MRI is the possibility of assessing T1 tumors that could be treated by transanal endoscopic microsurgery. However, MRI is better for visualizing most radiological prognostic features in rectal or anal cancer such as a circumferential resection margin less than 1 mm, T stage at T1-T2 or T3 tumors with extramural extension less than 5 mm, absence of extramural vascular invasion, N stage at N0/N1, and tumors located in the middle or upper third of the rectum. It can also evaluate the intersphincteric space or levator ani muscle involvement. Increased signal on diffusion weighted imaging (DWI) and low apparent diffusion coefficient (ADC) values as well as an irregular contour and heterogeneous internal signal intensity seem to predict the involvement of pelvic lymphatic nodes better than their size alone. Computed tomography as well as other examination techniques, including digital rectal examination, contrast edema, recto- and colonoscopy, are less useful in staging of rectal cancer but still are very important screening tools.

Giant vulvar lipoma in an adolescent girl: a case study and literature review.

A rare case of a giant vulvar lipoma that developed in an adolescent is presented. A review of the world literature of 15 cases that occurred prior to adulthood confirmed that they tend to occur on the right side of the vulva.

Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison.

Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected. THE AIM OF THIS PAPER: The aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae. MATERIAL AND METHODS: The results of endosonographic and magnetic resonance examinations performed in 2011-2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case. RESULTS: In determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment - 41% and between endosonography and magnetic resonance - 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%. CONCLUSIONS: Magnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53-67%; the highest level of agreement was noted for the assessment of branching.

Neck sweat gland cancer hemorrhage. Case study.

BACKGROUND: This paper reports a case of an 87-year-old female patient who was admitted for an emergency operation due to massive hemorrhage of an ulceration localized on a huge neck tumor. Post-interventional diagnosis indicated hidradenocarcinoma. Hidradenocarcinoma is a rare skin neoplasm. It can coincide with adenoma, may develop through its malignant transformation or develop as a malignant tumor from the beginning. It may be found in all dermal localizations. It may develop metastases or appear in the diffuse form. MATERIAL AND METHODS: Surgical excision of the tumor was performed obtaining a surgical margin, completed with excision of local lymph nodes and multiple layer suturing. Due to lack of the patient's consent, she has not been qualified for adjuvant therapy. RESULTS: Control examination 6 and 12 months later showed no signs of local recurrence or lymph node metastasis. CONCLUSION: Surgical excision of apocrine hidradenocarcinoma with a surgical margin could present a good therapeutic effect in spite of lack of adjuvant therapy.

Effectiveness of Lichtenstein repairs in planned treatment of giant inguinal hernia - own experience.

INTRODUCTION: Occurrence of giant inguinal hernias is not frequent because of growing medical awareness in the community as well as progress in surgical treatment in this field. AIM: To evaluate the effectiveness of repairs using the Lichtenstein technique in scheduled treatment of giant inguinal hernias. MATERIAL AND METHODS: Between 2006 and 2010 in the Department of Surgery with the Subdepartment of Proctology, Hospital at Solec in Warsaw, 909 repairs of inguinal hernia were performed, including 15 patients (1.65%) with the diagnosis of giant hernia. In 3 cases it was direct inguinal hernia and in 12 cases indirect inguinal hernia. All giant hernias occurred in male patients between 33 and 87 years of age (mean age 65 years old) and developed for many years, median of 14.2 years. All patients underwent scheduled repairs using the tension-free Lichtenstein technique. A non-absorbable polypropylene mesh was used for hernioplasty. Exact Fisher's test (p < 0.01) was used for statistical analysis. RESULTS: In all cases contents of the hernial sac consisted of loops of small intestine, colon and omentum. Early complications occurred in 11 patients (73%) in the group of patients with giant hernias, whereas in the remaining group of patients early complications occurred in 53 patients (5.9%). The difference was statistically significant. In the group of patients with giant hernias no recurrence was observed over the observation period ranging from 6 months to 4.5 years. In the remaining group of patients recurrences occurred in 23 patients (2.6%). CONCLUSIONS: The Lichtenstein technique of repair is effective in management of giant inguinal hernias. A statistically significantly higher percentage of complications was observed in the group of patients with giant hernias as compared to the remaining group of patients with inguinal hernias. Patients with giant hernias require proper preparation for surgery, especially in relation to their respiratory efficiency.

Utility of transperineal and anal ultrasonography in the diagnostics of hidradenitis suppurativa and its differentiation from a rectal fistula.

INTRODUCTION: The pathogenesis of hidradenitis suppurativa (HS) is not fully understood. There exist several theories, in which mechanical factors, genetic factors, as well as immunological dysfunction of lymphocytes are suspected. Clinically, this entity is frequently mistaken for anal fistula with consequently wrong treatment. We aim to determine the utility of transperineal ultrasound (TPUS) and anal ultrasound (AUS) in the diagnosis of HS and its differentiation from an anal fistula. MATERIAL/METHODS: Retrospective analysis was performed on 51 patients (5 females, 46 males) aged 20-71 years (mean age 47.5), who were operated on in the years 2006-2011 for HS in the area of the anus and perineum, and pre-operatively had been imaged with TPUS and AUS. Sixty-seven operations were analyzed, as 11 patients were operated on more than once due to HS recurrence. RESULTS: In 66 out of 67 cases (98.5%), the pre-operative TPUS and AUS were in accordance with the intraoperative findings. Only in 1 patient was a pilonidal cyst diagnosed intraoperatively. In all 67 patients, the TPUS showed typical fluid-solid changes localized in the subcutaneous adipose tissue. In 6 out of 67 cases of HS (8.9%) AUS showed an anal fistula coexisting with the HS. In 2 cases (2.9%) a skin malignancy coexisting with HS was found. DISCUSSION: TPUS is an accessible imaging method, which confirms the typical localization of changes of HS, and together with AUS it allows for the proper differentiation of HS from an anal fistula or an abscess.

Usefulness of electrosurgical techniques in thyroid gland surgery.

UNLABELLED: Wide propagation of new generation of electrosurgical devices such as bipolar vessel sealing systems (eg. Thermostapler® by EMED) enabled seamless closing of blood vessels with a diameter up to 7 mm while maintaining the necessary safety margin, as well as reducing the duration of the operation. We decided to verify these reports in our material. AIM OF THE STUDY was comparison of thyroid surgery performed with the electrocautery tool - Thermostapler ® by EMED with surgery using classic hemostasis technique to evaluate the operative time and complications in the form of bleeding, recurrent laryngeal nerve paralysis, symptoms of hypoparathyroidism, and wound infection. MATERIAL AND METHODS: We retrospectively analyzed 256 patients operated in the Department of General and Proctological Surgery Solec Hospital in Warsaw due to inert thyroid goitre. All patients underwent total thyroidectomy. Patients were divided into two groups. The first group consisted of 126 patients operated in 2000, using classic techniques of hemostasis. While the second group consisted of 130 patients operated in 2007-2008 with Thermostapler®. We compared duration of surgery and the incidence of postoperative complications. RESULTS: The operative time was significantly shorter (average 18 minutes) in the second group of patients. We also recorded a statistically significant decrease in the incidence of complications in the group operated with Thermostapler. CONCLUSIONS: Use of bipolar vessel sealing system in a decisive manner shortens the duration of operation. Use of bipolar vessel sealing system also enables a radical reduction in the incidence of complications rate such as bleeding, recurrent laryngeal nerve paralysis, symptoms of hypoparathyroidism, and wound infection. In the future, similar studies should be performed to assess the real costs resulting from the use Thermostapler®.

[Current possibilities of examination and preservative treatment in endometrial hyperplasia]. / Aktualne mozliwosci monitorowania oraz zachowawczego leczenia nienowotworowych rozrostów blony sluzowej macicy.

Endometrial hyperplasia is one of the most frequent reasons of pre- and menopausal bleeding. In recent years, knowledge of biology of hyperplastic endometrium has changed some medical guidelines in a group of patients diagnosed with endometrial lesions. In many cases radical procedures have been replaced with preservative treatment, especially for those women who wished to spare their uterus. Also, in many high-risk surgical procedures there are a number of algorithms which allow to perform non-radical treatment in those cases. Enforcement of those strategy should be linked to precise examination of endometrium morphology Summarizing, a preservative treatment in case of endometrial hyperplasia needs sensitive and specific tests which determine safety limits of the procedure. This paper has presented current possibilities of examination and non-radical treatment of endometrial hyperplasia.

Prevalence of chronic venous disorders among employees working in prolonged sitting and standing postures.

Research was conducted to determine the prevalence and severity of chronic venous disorders (CVD) among people working in prolonged sitting or static standing postures. Clinical examination and duplex Doppler sonography were performed on 126 employees working in a sitting (96 individuals) or a standing posture (30 individuals). Evidence of CVD was found in 59.4% of individuals working in a sitting posture and in 83.4% of those working in a standing posture, and was significantly higher in employees working in a standing posture (p = .015). Incompetent perforating veins and vena saphena magna valves, and bilateral changes were the more frequent signs of CVD. The investigation showed that prolonged standing and sitting at work increases risk of developing CVD. Further, people working in a standing posture are at a significantly greater risk for CVD than those working in a prolonged sitting posture. They should thus be the subject of specific prophylaxis interventions.

Retinol-binding protein 4 in adipose and placental tissue of women with gestational diabetes.

In the present study, we evaluated serum levels of retinol-binding protein 4 (RBP4) and the expression of RBP4, glucose transporter-4 (GLUT4) and peroxisome proliferator activated receptor gamma (PPARγ) mRNA (using quantitative real time-PCR) in subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and placental tissue obtained from patients with gestational diabetes (GDM) and healthy pregnant women. Serum RBP4 concentrations and its expression in SAT were higher in the women with GDM than in the controls (p = 0.03). No association between serum or tissue RBP4 and the indices of insulin resistance was noted. In the GDM group serum RBP4 correlated with its mRNA expression in SAT (r = 0.67, p = 0.007). Stepwise regression analysis revealed that RBP4 mRNA expression in SAT was independently predicted by GLUT4 mRNA expression (ß= 0.59, p = 0.003) and the presence of GDM (ß=0.46, p = 0.01), whereas RBP4 mRNA expression in VAT was related to PPARγ mRNA expression (ß= 0.64, p = 0.0003) and the patient's age (ß= -0.38, p = 0.03). In conclusion, our results suggest that the elevated expression of RBP4 in SAT may contribute to the increase in circulating RBP4 in GDM subjects.

The accuracy of a postprocessing technique--volume render mode--in three-dimensional endoanal ultrasonography of anal abscesses and fistulas.

OBJECTIVE: This study aimed to evaluate the accuracy of a 3-dimensional volume render mode endoanal ultrasonography in the assessment of anal abscesses and fistulas. PATIENTS AND METHODS: Three-dimensional endoanal ultrasonography was performed preoperatively in 62 patients with clinical diagnoses of an anal abscess and/or an anal fistula. The accuracy of a volume render mode endoanal ultrasonography was evaluated blindly by 2 observers through a retrospective analysis of all the stored images of anal abscesses and fistulas. Differences in classification of the type of anal abscesses and in determination of the type and location of internal openings of anal fistulas were assessed. RESULTS: In classification of the primary tract, the agreement between the volume render mode endoanal ultrasonography and surgery was much higher than that for the 3-dimensional endoanal ultrasonography (marginal homogeneity test P > .1, κ = 0.96, and marginal homogeneity test P = .0048, κ = 0.28, respectively). In localizing the internal openings and in classifying anal abscesses, the agreement for both methods with surgery was identical. The interobserver agreement showed complete agreement (100%) with regard to luminance and thickness parameters and very high accuracy for the opacity and filter parameters. CONCLUSIONS: This study demonstrated that volume render mode endoanal ultrasonography is a useful adjunct method to the 3-dimensional endoanal ultrasonography, showing better classification results of the types of anal fistulas.

Anal endosonographic findings in women after vaginal delivery.

OBJECTIVE: To estimate a frequency of obstetric anal sphincters defects in women after vaginal delivery. METHODS: The study included 102 women, aged from 16 to 40 years (mean age 28.6 years). 28 women had perineal lacerations of 3rd and 4th degree. 22 women had instrumental delivery. Anal endosonography was performed on all participants using BK Medical scanner Pro focus with a 3D endoprobe during the first week after delivery. Starck's classification was used to score sphincters defects. RESULTS: The endosonographic images were abnormal in 8 out of 102 women (7.8%). Follow-up examinations after 6 weeks confirmed defects in 6 out of 102 women (5.8%). Five women had external anal sphincter torn, and 1 woman had both sphincters, internal and external, defected. Discordance between endosonographic diagnosis of defect and clinical assessment of sphincters continuity was demonstrated in 6 (5.9%) out of 8 initially found, including 2 (1.9%) false endosonographic results and 4 (3.9%) false clinical diagnosis (occult sphincter defects). The endosonography sensitivity and accuracy in sphincter defect diagnostic amounted to 100% and 98%, respectively. CONCLUSIONS: (1) Anal sphincters' tears in symptomatic women are not as frequent as it was believed. (2) The defect diagnosis in the first week after delivery should be verified by a follow-up endosonography in 6 weeks, after regression of the edema and hematoma.