Graciloplasty for Anal Incontinence-Is Electrical Stimulation Necessary?

INTRODUCTION: Anal incontinence brings lot of social embarrassment, mental distress, dignity loss, anxiety, low confidence, and eventually a low self-esteem with a restricted social life to the affected person. Surgical repair is the mainstay of treatment for anal incontinence. However, some patients need additional procedures such as gluteoplasty, graciloplasty (adynamic and dynamic), artificial bowel sphincter, and sacral nerve stimulation, which help to reinforce or augment the anal sphincter. METHODS: A retrospective analysis of 17 patients who underwent adynamic graciloplasty for reconstruction of anal sphincter from January 2008 to December 2017 was done. Demographic profile, fecal incontinence scores (Wexner score and KAMM score), and anal manometric findings were recorded pregraciloplasty and postgraciloplasty. RESULTS: Of the total 17 patients, 9 were males and 8 were females. Satisfactory continence was achieved in 13 patients out of 17 (76.47%). Continence was defined as satisfactory for patients having a postoperative Wexner score of 2 or less and KAMM score of 4 or less. It was considered to be poor if the Wexner score was greater than 6 and KAMM score was greater than 8 in the follow-up period or if the stoma was not reversed. CONCLUSIONS: Unstimulated or adynamic graciloplasty is a relatively safe procedure, has a short learning curve, is affordable, and avoids the additional implant-related complications. We feel that the unstimulated graciloplasty still has a significant role in the management of anal incontinence.

Spontaneous liver rupture: A report of two cases.

Spontaneous bleeding due to a non traumatic liver rupture is a rare occurrence. However, it is associated with high morbidity and mortality. Usually the predisposing factors are like Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in pregnant women and other liver diseases. It is generally diagnosed by imaging studies such as ultra sonogram or computerized tomogram (CT). Due to its rarity no standard treatment has been described. Here, we report two cases of spontaneous rupture of normal liver in two young males. They presented with severe shock and hemoperitoneum. The diagnosis was confirmed by CT. They were managed surgically. In case of hemoperitoneum, spontaneous liver rupture should be considered. An early aggressive resuscitation and appropriate intervention gives better outcome.

The effect of autologous bone marrow-derived cells on healing chronic lower extremity wounds: results of a randomized controlled study.

Case studies suggest that bone marrow-derived stem cells may improve chronic wound healing. A prospective, randomized, clinical study was conducted to compare the rate of healing chronic lower limb wounds in patients with diabetes mellitus whose wounds were treated with topically applied and locally injected bone marrow-derived cells or whole blood (control). Of the 48 patients participating in the study, 25 were randomized to study treatment and 23 to control treatment. At baseline, no significant differences were observed between the two groups for patient age (average for treatment group was 54 years, 3 months; range 33 to 76 years and for the control group 58 years, 7 months; range 28 to 69 years), comorbidity (82% in the treatment group and 78% in the control group had diabetes mellitus), ulcer history (mean duration was 14.28 months in the treatment group and 10.21 months in the control group; SD 0.28), or baseline area (mean was 65.32 cm2 in the treatment group and 48.83 cm2 in the control group). After obtaining informed consent, all wounds were surgically debrided. Wounds of study participants randomized to the treatment group were injected and oversprayed with a total of 5 cc of autologous bone marrow-derived cells. Using a similar procedure, the wounds of patients randomized to the control group were injected with 5 cc of autologous peripheral blood. All wounds were covered with saline-moistened gauze and cotton pads. Patients were followed for a maximum of 3 months. The average decrease in wound area at 2 weeks was 17.4% (39.6-43.4 cm2) in the treatment group compared to 4.84% (41.6-42.8 cm2) in the control group. After 12 weeks, the average decrease in wound area was 36.4% (SD 0.48) in the treatment group compared to 27.32% (SD 0.32) in the control group. No adverse events were observed. None of the patients complained of significant pain or discomfort following the procedure, no wound infections occurred, and all patients reported resumption of normal daily activity the day after the procedure. The results of this study show that a single application of autologous bone marrow-derived cells increases the rate of healing chronic lower extremity wounds in the early weeks of treatment. Additional studies to elucidate the treatment mode of action and optimal application frequency as well as comparisons between this and other treatment modalities are warranted.

Transanal excision of anorectal lesions--a single centre experience.

BACKGROUND: Transanal excision is commonly used to treat lesions of the anorectum. It avoids the morbidity of radical pelvic surgery, while allowing for complete histopathological examination of the lesion. AIM: The aim of this study was to look at the spectrum of disease treated by transanal excision, and their outcomes, in a tertiary care institute. METHODS: Records of patients who underwent transanal excision between 2004 and 2008 were reviewed. Patients were divided into three groups. (1) Resection for benign disease (2) Curative and (3) Palliative resection for malignant disease. RESULTS: Forty six patients underwent transanal excision, 21 for benign and 25 for malignant disease, 20 with curative and 5 with palliative intent. Tubulovillous adenomas and hyperplastic polyps were the commonest benign lesions. The mean follow up was 18.6 months (4-49). There was one recurrence and one patient returned with liver metastasis. Seventeen patients with adenocarcinoma, two with melanoma and one with verrucous carcinoma underwent curative resection. Three required a second local excision and two abdominoperineal excision. Mean follow up was 28 months (4-63). There were three recurrences, one requiring a local excision and two abdominoperineal excision. Four patients with malignant melanoma and one with adenocarcinoma underwent palliative resection. All these patients had good symptom palliation. CONCLUSION: Transanal excision, when technically feasible, remains the treatment of choice for benign disease of the rectum. It offers good palliation of local symptoms in advanced malignant disease. It can be used in a carefully selected group of patients with early rectal cancer.

Anal sphincter repair for fecal incontinence: experience from a tertiary care centre.

AIM: Structural anal sphincter damage may be secondary to obstetric anal sphincter injury, perineal trauma or anorectal surgery. We reviewed the spectrum of anal sphincter injuries and their outcomes in a tertiary care colorectal unit. METHODS: Data of patients who underwent anal sphincter repair between 2004 and 2008 were analyzed retrospectively. Outcomes were compared with respect to etiology, type of repair, previous attempts at repair and manometry findings. Outcomes were defined as good or poor based on patient satisfaction as the primary criteria. RESULTS: Thirty-four patients underwent anal sphincter repair. Twenty-two injuries were obstetric, eight traumatic, and four iatrogenic. All patients underwent overlap sphincteroplasty with six additional anterior levatorplasty and seven graciloplasty. Twenty-three (67.6%) patients had a good outcome while nine (26.4%) had a poor outcome. All patients who had augmentation anterior levatorplasty had a good outcome. Fifty percent of patients with a previous sphincter repair and 42.9% requiring augmentation graciloplasty had a poor outcome. Median resting and squeeze anal pressures increased from 57.5 to 70 cmH2O and 90.25 to 111 cmH2O in those with a good outcome. CONCLUSIONS: Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

Selective histopathology in cholecystectomy for gallstone disease.

BACKGROUND: Incidental gallbladder cancer is found in upto 1% of cholecystectomy specimens for gallstone disease. Currently, in our institution, all gallbladder specimens are sent for routine histopathology, to rule out incidental gallbladder carcinoma. This study was aimed at assessing the need for routine histopathology of gallbladder specimens after cholecystectomy for gallstone disease. METHODS: Hospital records of all patients undergoing cholecystectomy for gallstone disease over a ten-year period, between 1998 and 2007, in a single surgical unit were reviewed. RESULTS: A total of 1312 patients underwent cholecystectomy for gallstone disease. Gallbladder carcinoma was detected in 13 patients. Macroscopic abnormalities of the gallbladder were found in all the 13 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. CONCLUSION: Gallbladder carcinoma is associated with macroscopic abnormalities in all cases. Therefore histopathology should be restricted to only those specimens which reveal a macroscopic abnormality. This would identify all cases of incidental gallbladder carcinoma, at the same time decreasing cost and pathological work load.

Thyroidectomy under local anaesthesia in India.

Thyroid surgery under local anaesthetic seems to be a forgotten skill. We share our experience and suggest that it is a safe and economical option with negligible morbidity.

Adult idiopathic ileosigmoid intussusception prolapsing per rectum.

Ileosigmoid intussusception can lead to ischemia and necrosis of either the ileum or sigmoid colon. Ileosigmoid intussusception as a mass prolapsing per rectum in an adult has not been previously reported. We report a 50-year-old man with such a presentation. He recovered uneventfully after subtotal colectomy.

Retroperitoneal lymphatics on CT and MR.

We report the CT and MRI appearances of dilated retroperitoneal lymphatic channels in six patients. In two patients, these dilated channels resembled a mass of confluent low-density lymph nodes on CT. On MR urography the lymphatic channels in all six patients were seen as a meshwork of multiple tubular, tortuous, fluid-filled structures in the retroperitoneum of the abdomen and pelvis. On axial T1W images, these channels were seen as numerous, interconnected small, nodular and streaky intensities and as a cloak of diffuse homogenous hyperintensity on T2W axial images. The lymphatic nature of these abnormalities was confirmed at surgery in one patient. In another patient, the calibre and number of the dilated retroperitoneal channels reduced following anti-filarial therapy. The remaining four patients presented with chyluria.

Surgical management of thoracic outlet syndrome: a 10-year experience.

BACKGROUND: Thoracic Outlet Syndrome (TOS) refers to compression of the neurovascular structures in the region between the scalene muscles and the first rib, or by anatomical abnormalities such as cervical rib, fibrous bands and other variations in the scalene musculature. METHODS: Our experience with 63 consecutive operations for TOS, over a period of 10 years, has been reviewed. Preoperative symptoms and signs, investigations, surgery done, complications and the outcome of surgery are analysed. RESULTS: A total of 60 patients underwent 63 operations for decompression of TOS. All the 63 first ribs, were excised by the transaxillary approach. In seven patients (16%), a combined transaxillary and supraclavicular approach was used. There was no operative mortality in this series. The operative complications included pneumothorax in four patients (6.3%), which was treated by insertion of chest drain, and lower brachial plexus neuropraxia in two patients (3%), which improved with conservative management. The mean duration of postoperative hospital stay was 3.6 days. At 12 months following surgery, 56 patients (93%) had complete or partial relief of symptoms and only four patients (6.6%) had no relief of symptoms. CONCLUSION: The results of the present study confirm that transaxillary excision of the first rib is a surgical procedure associated with very low morbidity and excellent relief of symptoms. It can therefore be offered as an early option for patients with thoracic outlet syndrome. It may be combined with the supraclavicular approach if exposure of the subclavian artery is required for vascular reconstruction.

Traction as a cause of gallbladder avulsion.

Following isolated blunt trauma to the abdomen, a 25-year-old man developed peritonitis. Laparotomy revealed a band between the transverse colon and gallbladder, with partial avulsion of the latter. Avulsion of the gallbladder is a rare injury and, to the best of our knowledge traction has not been described as a mechanism of injury.

Omental lymphangioma in an adult.

Lymphangiomas are commonly found in the head and neck region. They are commonly seen in children while mesenteric cysts are more common in adults. We report the case of a 34-year-old man who was diagnosed as having a lymphangioma.