Partial Division of Puborectalis Muscle with Lateral Internal Sphincterotomy: A Novel Surgical Technique for Management of Anal Hypertonia-Associated Anismus.

BACKGROUND: Treatment of anismus usually starts with biofeedback therapy and injection of botulinum toxin in the puborectalis muscle (PRM). Patients refractory to conservative treatment may require surgery. The present cohort study aimed to assess a combined technique of partial division of PRM and tailored lateral internal sphincterotomy (LIS) in treatment of anismus. METHODS: Patients with anismus who failed conservative treatments were assessed clinically and with high-resolution anal manometry (HRAM), EMG, defecography, and underwent combined partial division of PRM on one side and tailored LIS on the contralateral side. Main outcome measures were improvement in symptoms and quality of life, changes in HRAM and defecography postoperatively, complications, and patient satisfaction. RESULTS: A total of 73 patients (61 male) of a mean age of 37 years were included to the study. In total, 89% of patients showed a significant improvement in symptoms at 12 months postoperatively. The mean modified Altomare score decreased significantly (p < 0.0001) from 16.4 ± 1.7 to 6.6 ± 1 at 12 months postoperatively. There was a significant increase in the mental and physical components of quality of life at 12 months postoperatively. The numbers of patients with positive findings of anismus in postoperative defecography, EMG, and balloon expulsion test were significantly less than before surgery. The mean total satisfaction score was 86.5 ± 8.7. Five (6.5%) patients developed minor complications. CONCLUSION: Partial division of puborectalis muscle combined with LIS is an effective technique in the management of anal hypertonia-associated anismus with satisfactory results and low incidence of complications.

Role of vitamin D supplements in prevention of hungry bone syndrome after successful parathyroidectomy for primary hyperparathyroidism: A prospective study.

BACKGROUND: We postulated that the preoperative correction of vitamin D levels can significantly reduce the incidence of hunger bone syndrome among patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS: We performed a prospective, randomized, open-label study on 102 patients with primary hyperparathyroidism and coexisting vitamin D deficiency who were scheduled to undergo parathyroidectomy. Patients were divided into the following two groups: group I which included 52 patients who did not receive preoperative vitamin D supplementation; and group II which included 50 patients who received cholecalciferol 1000-2000 IU daily or 50000 IU weekly until they achieve vitamin D levels >20 ng/mL (group IIa = 25 patients) or vitamin D levels >30 ng/mL (group IIb = 25 patients). RESULTS: The incidence of hunger bone syndrome in group IIb was lower than group I and group IIa (8% versus 16% versus 23%, respectively); however, this difference did not reach the level of statistical significance (p = 0.22). Patients with hunger bone syndrome were significantly younger and had higher serum phosphorus, alkaline phosphatase, magnesium, and bone mineral density at baseline than patients without hunger bone syndrome. On the other hand, patients with hunger bone syndrome had significantly lower 25-hydroxyvitamin D at baseline than patients without hunger bone syndrome (p = 0.001). The ROC curve showed that the baseline level of serum 25-hydroxyvitamin D was not an independent discriminator of hunger bone syndrome (area under curve = 0.21 (95% CI: 0.06-0.34); p = 0.011). CONCLUSIONS: Preoperative course of vitamin D supplements has no preventive role on the postoperative incidence of hunger bone syndrome among patients with primary hyperparathyroidism and coexisting vitamin D deficiency undergoing parathyroidectomy.