Novel surgical procedure in design of advancement endorectal flap in the surgical treatment of complex anal fistulas.

INTRODUCTION: Anal fistula is a common disease with incidence of 5.6 per 100,000 women and 12.3 men. It is most often of cryptoglandular origin. The aim of this study is to evaluate our experience with patients treated for complex anal fistula with our own complex surgical procedure with advancement endorectal flap. METHODS: 524 patients with complex anal fistulas who were sent to our surgical clinic from January 2005 to the end of December 2022 were in- cluded in the study. We established the diagnosis by detecting the fistula tract by physical examination, anoscopy, probing the fistula tract and endorectal ultrasonography. We performed a complex operation together with the construction of the advancement endorectal flap in our own modification for all patients. RESULTS: Primary surgical intervention in a group of 326 patients with complex anal fistulas (excluding patients with Crohn's disease) was successful in 283 (87%) patients. We identified advancement endorectal flap defect in the postoperative period in 17 (5.2%) patients, soiling in 16 (4.9%) and flatus incontinence in 9 (2.7%) patients. In a group of 120 patients after multiple surgeries (excluding patients with Crohn's disease), our surgical procedure was successful in 92 (76.6%) patients. In the postoperative period, we identified a advancement endorectal flap defect in 6 (5%) patients, soiling in 8 (6.6%) and flatus incontinence in 3 (2.5%) patients. CONCLUSIONS: The construction of the advacement endorectal flap was curative and without affecting the level of anal continence in 87% of patients after primary surgical intervention and in 76.6% after multiple surgical procedures. Complex surgery with the construction of the advancement endorectal flap according to our procedure preserves the function of the sphincters and has a relatively low percentage of recurrences. The number of previous surgical interventions had no affect on the level of anal continence.

[Concomitance of acute cholecystitis and acute appendicitis]. / Koincidencia akútnej cholecystitídy a akútnej apendicitídy.

Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate. However, they are only rarely described simultaneously. Authors describe the course of disease, diagnostics and surgery solution of disease. They report, that there are many factors, which play important role in the process of diagnostics and treatment of patient. They emphasis individual access not only of patients view, but also individual acces and view of surgeon. Because of rare coincidence of both diseases, there are many questions, but answers miss.Key words: acute cholecystitis acute appendicitis coincidence.

[Heterotopic mesenteric ossification]. / Heterotopická mezenteriálna osifikácia.

Heterotopic mesenteric ossification (HMO) is a rare disease inducing pathological bone tissue formation in the abdominal cavity after multiple operational traumas. The authors present an unusual case of mesenteric ossification formation in a 30 year-old man after surgery due to status ileosus on the basis of intestinal incarceration. After being released into home treatment the patient had to be hospitalized again and reoperated. During the next six weeks, the patient was reoperated three more times due to intestinal status ileosus and significant leaking of the entero-cutaneous fistula. Despite intensive parenteral hyperalimentation the patients condition did not improve and metabolic breakdown became fatal for the patient. Pathophysiology of the mechanism of bone tissue formation in soft tissues is unknown.

[Choledochal cyst complication of pregnancy]. / Cysta choledochu ako komplikácia gravidity.

Authors in this case report describe rare complication of pregnancy. Ultrasound examination showed cystic lesion in abdominal cavity. It was indicated caesarean section because of deterioration of patient's condition. After the removal of foetus it was peroperative found cystic lesion in subhepatal area in right mesogastrium. Cystic lesion compressed stomach, colon transverse and loops of small intestine. After the revision of abdominal cavity and local finding surgeon detected choledochal cyst. It was resected and sutured hepaticojejunoanastomosis.

[Acute intestinal ischaemia]. / Akútna intestinálna ischémia.

In spite of introduction modern diagnostics and therapeutics modalities in clinical practice diagnostics of acute intestinal ischaemia is very difficult. Acute intestinal ischaemia is rare cause of acute abdominal dissease but results of surgical treatment and prognosis of the patients with acute intestinal ischaemia is very poor. The aim of study is occurence, diagnostics and therapeutics possibilities of acute intestinal ischaemia, because tretament of acute intestinal ischaemia have high rate of mortality. Authors claiming on own small set of patients that in diagnostics of acute abdominal pain everything in once mind on acute intestinal ischaemia.

Combined parasacral, vaginal and endorectal approach in surgical treatment of giant rectocele.

Authors operated on their Surgical departement 67 years old women with incomplete evacuation, and digital support during defecation, giant rectocele and massive vaginal vault prolaps. Authors realized cinedefecography and detected giant rectocele, depth was 8 cm, anorectal angle was 120 degrees. They stated Resting pressure 40 cm H2O, and Maximum squeeze pressure 50cm H2O by anorectal manometry. Authors verified external anal sphincters defect by endoanal ultrasound and determined Pudendal nerve terminal motor latency (PN TML) and recorded pathologic values of n.pudendal latency ( left branch 2,7 msec., right branch 4,3 msec). In concerning massive vaginal vault prolaps, huge rerectocele and clinical incompletely evacuation with self digital support during defecation with present defect od external anal sphincters and pathologic values of PN TML, authors indicated and made combined transvaginal, endorectal and perineal reconstructive operative performance. In the present time two years after the surgery radiologic mean depth of the rectocele was significantly reduced (preoperatively 8cm; postoperatively 1 cm). Anorectal angle is 100 degrees. Values of the PN TML is normaly (left branch of n. pudendalis 1,7 msec and right branch of n. pudendalis 1,9 msec). Authors recorded Resting pressure 60 cm H2O and Maximum squeeze pressure 110 cm H2O by anorectal manometry. They didnt visualized any external anal sphincters defect by anal ultrasound. Postoperatively difficult evacuation completely disappeared and digital support was no longer necessary during evacuation.

[Postoperative adhesions, the everlasting topical subject]. / Pooperacné adhézie, stále aktuálny problém.

Creation of postoperative adhesions is a part of every abdominal operation. The authors analyse 320 patients operated for ileus in last 7 years. 118 patients were operated for adhesive ileus. Most common reoperations for ileus are after radical gynecological operations and inflammatory intraabdominal diseases. The creation of adhesiones depends on preoperative mechanical or chemical damage of tissues and peritoneum, bacterial infection and irradiation. The major complication of intraabdominal adhesions are disturbances of bowel function what leads to subileus or ileus. Authors present therapeutical possibilities and prefer laparoscopic operations.

[Internal hernias--uncommon causes of the status ileosus]. / Vnútorne hernie--menej castá prícina ileóznych stavov.

Internal hernia is an uncommon cause of acute intestinal obstruction with. Preoperative diagnosis of an internal hernia is difficult because of the lack of specific signs. Only a few cases of internal hernia have been successfully diagnosed, however, most cases (74%) were initially diagnosed as intestinal obstructions. Authors present the case of the patient with the history of resection of gaster sec. Billroth II with gastroenteroanastomosis. The symptoms of the internal hernia were vomiting, abdominal pain and leaded to an emergency operation. An incarceration of the bowel retroanastomotic under the Braun anastomosis. The obstruction was released by the traction of the bowel and the abnormal opening was sutured to prevent recurrence.

[Endoanal transrectal ultrasonography in the diagnosis and care of patients with rectal carcinoma]. / Endoanálna transrektálna usg v diagnostrike a dispenzarizácii pacientov s karcinómom rekta.

Endoanal sonography in rectal tumor is diagnostically significant. This method helps to specify the prognosis of patients with malignant rectal tumor. Endoanal sonography examination before the operation corresponds with postoperative histopathological findings (endoanal sensitivity uT--91.6%). The method is most important during the follow-up of patients after surgery and in ascertainment of local recurrence (endoanal sensitivity recidivation uT--86%). The authors present their experience with 402 patients. The advantages of endoanal transrectal sonography are possibilities of determination of staging the tumors which can not be reached physically, information of the way of spreading and penetration depth of the tumor, information about their growth, simplicity and easy repetition of the process and economical convenience. (Tab. 2, Fig. 2, Ref. 14.)

[An effective and achievable system of ultrashort antimicrobial prophylaxis in colorectal surgery]. / Efektívny a dostupný systém ultrakrátkej antimikrobiálnej profylaxie v kolorektálnej chirurgii.

The authors describe their own system of ultrashort antimicrobial prophylaxis in colorectal surgery. They give an account of two years' experience with their system of ultrashort antimicrobial prophylaxis and demonstrate its effectiveness, feasibility and economic advantages on a group of 113 patients. They implement the prophylaxis of wound infection in colorectal surgery by antibacterial substances which are available in all health facilities in Czechoslovakia. In a group of 113 patients after elective operations of the colon and rectum they recorded, when using their system of ultrashort antimicrobial prophylaxis, 7.07% wound complications.