Biofeedback therapy for outlet dysfunction: our experience.

Biofeedback is an important therapeutic option in patients with outlet dysfunction. A total of 75 patients referred to our proctological division from March 2004 to June 2008 and complaining of chronic constipation were studied by history, physical examination, anorectal functional tests and a structured questionnaire. Patients were treated with biofeedback plus electrical stimulation or both biofeedback plus electrical stimulation and surgery. Sixty of the 75 patients were treated with biofeedback only; and 15 with both treatments. All patients underwent, on average, twice weekly 15-minute EMG-biofeedback training sessions followed by 5 minutes of electrical stimulation. At 6 months' follow-up all physiological parameters with the exception of anal squeeze pressure showed a significant improvement (p < 0.05); there were reductions in sensation of incomplete evacuation (from 72 to 29.3 percent), in difficult stool passage (from 76 to 18.7 percent), and in the use of laxatives, enemas or digital manoeuvres (from 88 to 40 percent). At a telephone follow-up at 1 year, an improvement in satisfaction was reported by 77.3% of patients (58/75). The results of this study confirm that biofeedback plus electrical stimulation produces an improvement in bowel symptoms in patients with outlet dysfunction, as well as underlining the importance of anorectal functional tests as a guide to the most appropriate treatment.

Parastomal hernia repair with the use of Parietex composite mesh: a technical note.

Parastomal hernia is an incisional hernia related to an abdominal wall stoma. The incidence ranges from 5 to 50% and only 10% of these require surgical treatment. The authors propose an innovative surgical technique for treatment of parastomal hernia. Many kinds of repair for paracolostomal hernias have been proposed: simple fascia repair, stoma relocation and repair with prosthetic devices. We describe a successful local repair and a new approach to treat this defect using a polypropylene mesh.

Biofeedback therapy for faecal incontinence: our experience.

Biofeedback combined with electrical stimulation is an appealing conservative therapeutic option in patients with faecal incontinence. A total of 51 patients with faecal incontinence referred to our proctological division from March 2004 to June 2008 were studied. All patients were treated with biofeedback plus electrical stimulation. All patients underwent, on average, twice-weekly 15-minute electromyography-biofeedback training sessions followed by 5 minutes of electrical stimulation. Patients satisfaction, physiological data, clinical symptoms and a modified Wexner score were used to assess improvement. At 6 months' follow-up, nearly all physiological parameters showed a significant improvement (p < 0.05) and there was a reduction in the loss of solid stool (from 78.4 to 27.5 percent), in the loss of liquid stool (from 100 to 29.4 percent), and in pad usage (from 74.5 to 17.6 percent). At 1-year follow-up, an improvement in satisfaction was reported by 41/51 of patients (80.4%). This study suggests that biofeedback plus electrical stimulation leads to a substantial improvement in faecal incontinence symptoms and underlines the importance of anorectal functional tests to examine and guide the management of patients with faecal incontinence.

Perineal hernia: a case of outlet dysfunction.

This article describes and discusses a successfully treated case of a primary posterior perineal hernia which is a rare cause of outlet dysfunction. A 46-year-old female patient had a 6 cm left para-anal protrusion and a 7-year history of outlet dysfunction. The perineal hernia orifice was closed via an abdominal approach using both a polypropylene mesh and a Parietex Composite Net. A rectopexy to the promontory of the sacrum was then performed. Moreover, after 6 months' follow-up, the patient presented a sense of incomplete evacuation and underwent a prolassectomy to treat a hidden rectal prolapse. This clinical case shows that the surgical treatment of a pelvic pathology can be successful for the correction of a serious functional defect such as outlet dysfunction.

Treatment strategies for chronic constipation: our experience.

Outlet dysfunction is responsible for 25% of all cases of chronic constipation. The aim of this article was to report our outcomes and investigate the efficacy of the different treatments that we have adopted to solve it. One hundred and twenty-six patients were treated with either surgery and/or biofeedback therapy. Ninety-seven of the 126 patients underwent surgery; 48 with hidden rectal prolapse: 44 underwent a stapled transanal rectal resection using a double stapler PPH-01 and 4 a single stapler PPH-01; 31 with rectocele and 18 with both hidden rectal prolapse and rectocele, respectively, underwent a stapled transanal rectal resection using a double stapler PPH-01. Thirteen of 97 patients showing outlet dysfunction in spite of surgery progressed to biofeedback therapy. 29 of the 126 patients were treated with biofeedback training only. Surgery helped 51.6% of treated for rectocele, 75% of those treated for hidden rectal prolapse, and 78% of patients treated for both rectocele and hidden rectal prolapse, respectively. Approximately 80% of patients treated with biofeedback alone and 67.8% of those treated with both surgery and biofeedback reported an improvement, respectively. Treatment of the outlet dysfunction can be difficult. The therapeutic option chosen for each subject in spite of a careful functional patient examination may not prove to be the most appropriate one. Our experience suggests that the surgery of the obstructed defecation could achieve better outcomes if a course of biofeedback therapy precedes it, above all in patients with both organic and functional disorders, and the repair of rectocele with stapled transanal rectal resection fails to resolve the outlet dysfunction in several cases.

Direct apoptotic effects of free fatty acids on human endothelial cells.

BACKGROUND AND AIM: Endothelial cell injury is a key event in the pathogenesis of diabetes-associated atherosclerosis and vascular complications. Increased apoptosis may contribute to the loss of endothelial integrity and leads to cardiovascular disease. This study was designed to elucidate whether high levels of free fatty acids (FFA) cause apoptosis and if so what is the possible role of insulin signaling alteration(s) in determining this effect. METHODS AND RESULTS: In human umbilical vein endothelial cells (HUVECs) cultured for 72h with high levels of FFA, apoptotic cells, detected by Annexin V-FITC and PI, were increased. Then we observed a decrease of Bcl-2/Bax ratio (pro-apoptotic condition), measured by RT-PCR and Western blot. As the Akt pathway is involved in insulin signaling and apoptosis, we investigated whether Akt mediated FFA apoptotic effects. HUVECs exposed to FFA showed an equal amount of total Akt protein content compared to controls. In HUVECs, FFA induced a significant decrease in phosphorylated active Akt. Furthermore, phosphorylated eNOS (active form) was decreased and cleaved caspase-9 (active form) was increased. These alterations were prevented when insulin at 10(-8)M was added in culture medium containing FFA. The insulin anti-apoptotic effect was prevented by Ly29400, a PI3K/Akt inhibitor. CONCLUSION: High levels of FFA cause HUVECs apoptosis through Akt inhibition; insulin can prevent these effects. Inappropriate FFA elevation may affect vascular endothelium by impairing cell survival via activation of apoptosis, thus contributing to the development of cardiovascular disease in type 2 diabetic patients.