Ultrasonographic assessment of patients referred with chronic anal pain to a tertiary referral centre.

BACKGROUND: Chronic anal pain is relatively common as a presentation to specialist physicians and surgeons. Currently, it is regarded as a functional disorder upon the exclusion of occult intersphincteric sepsis. Our study assessed an unselected cohort of patients presenting with chronic previously undiagnosed anal pain using routine ultrasonography. METHODS: All patients referred to a tertiary gastroenterology service between January 2005 and January 2008 with a diagnosis of chronic anal pain (>3 months duration with no clinical anorectal signs) underwent endoanal and static and dynamic transperineal ultrasound to assess for the frequency and pattern of occult intersphincteric sepsis. RESULTS: Of 1,580 patients referred, there were 146 presenting with chronic anal pain as a main symptom. Of these, 37 (25.3%) had intersphincteric sepsis (ISS) diagnosed with ultrasound examination with 17 undergoing evaluable surgery. There was a male preponderance (70.3%) with the diagnosis being made in 46% of cases after 6 months of symptoms and with 80.8% having posteriorly located sepsis. This occurred on a background of 62% having previous acute proctological conditions. There was complete ultrasonographic and operative concordance with 15 becoming asymptomatic after surgery at a mean follow-up of 6 months. CONCLUSION: Occult intersphincteric sepsis is not uncommon and is diagnosed using routine ultrasonography at the time of clinical presentation. Endoanal and transperineal ultrasound is recommended as part of the investigative armamentarium to exclude categorization as functional anorectal pain. This is currently not part of the Rome III coding for such a diagnosis suggesting a revision of these diagnostic criteria for the ultimate diagnosis of functional proctalgia.

Robotically assisted small intestinal strictureplasty in dogs: a survival study involving 16 Heineke-Mikulicz strictureplasties.

BACKGROUND: Robotically assisted surgery offers the advantages of improved dexterity and elimination of tremor over conventional laparoscopic surgery. There have been few studies to date, however, examining the role of robotics in intestinal surgery. This study was undertaken to determine the feasibility and safety of using a robotic surgical system in the performance of intracorporeal small bowel strictureplasties in dogs. METHODS: Using a robotic surgical system, a total of 16 strictureplasties were performed in the small bowel of eight dogs (two strictureplasties per dog). Using only intracorporeal robotic surgery, a 2.5 cm enterotomy was made longitudinally in the small bowel, and then closed in a Heineke-Mikulicz configuration with a one-layer running 3-0 braided absorbable suture (strictureplasty). All animals were allowed to survive for 7 days with prospective monitoring of bowel movements, level of activity, oral intake, and abdominal examination. After 7 days, necropsy was performed, examining all strictureplasty sites for signs of sepsis. The endpoints of the study were recovery of normal intestinal function (bowel movements), intraoperative and postoperative complications, and the appearance of the anastomoses at necropsy. RESULTS: There was no intraoperative morbidity or mortality. All eight dogs survived 7 days and recovered well. All dogs had a bowel movement on the first postoperative day, and appeared healthy throughout the study period. Necropsy revealed that all 16 strictureplasty sites were healing without signs of sepsis. The median time per strictureplasty was 65 min (range, 45-110 min). One dog developed a superficial wound infection at a trocar site. CONCLUSIONS: A robotic surgical system can successfully be employed in the performance of intestinal strictureplasties in dogs. This study supports further investigation into the role of robotics in intestinal surgery in humans.

Ulcerative colitis and sarcoidosis.

A 38-year-old woman with ulcerative colitis subsequently developed sarcoidosis. After ten years of recurrent episodes of colitis, she had presented with respiratory symptoms. The diagnosis of sarcoidosis was confirmed by mediastinal lymph node biopsy. Her respiratory symptoms gradually resolved without any specific treatment. Within the remission period of sarcoidosis, she underwent uneventful subtotal colectomy due to refractory colitis. Alterations in immune function and genetic susceptibility have been suggested to be present in both ulcerative colitis and sarcoidosis. However, the occurrence of both in the same patient has been rare. This is only the nineteenth case reported in the literature.

Laparoscopic cholecystectomy: what does affect the outcome? A retrospective multifactorial regression analysis.

BACKGROUND: The association between various factors and the postoperative outcome has not been thoroughly studied in laparoscopic cholecystectomy (LC). The aim of this retrospective study was to determine which factors significantly affect patients outcome after LC. METHODS: The medical and operative records of all consecutive patients who underwent LC at our institution from 1991 to 1996 were reviewed. The effect of age, medical and surgical history, duration of procedure, and setup (urgent or elective) on the postoperative complication rate and on the length of postoperative hospital stay (LOS) were analyzed using multiple linear regression and logistic regression analysis. Overall, 601 patients were included in the study. RESULTS: The factors that significantly prolonged LOS were age (p = 0.0145), acute cholecystitis (p = 0.0006), history of ischemic heart disease (p = 0.0332), and duration of procedure (p < 0.0001). A significantly higher postoperative morbidity rate was noted in patients who had a procedure longer then 2 h than in patients whose surgery required less the 2 h (13.6% vs 3.6%, respectively; p < 0.0001). Similarly, higher morbidity was noted in elderly patients than in younger patients (16% vs 6.1%; p = 0.0005). Other factors that significantly increased postoperative morbidity included acute cholecystitis (p = 0.023), a history of cholangitis (p = 0.018), and diabetes (p = 0.05). CONCLUSIONS: According to this study, advanced age, longer duration of procedure, and acute cholecystitis significantly increase both the postoperative morbidity and the LOS. History of ischemic heart disease significantly increases LOS, but does not increase morbidity after LC.

Gallstone ileus and Crohn's disease without biliary-enteric fistula: report of a unique case.

Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for fewer than 3% of laparotomies for intestinal obstruction. Patients with long-standing Crohn's disease have an increased risk of developing gallstone disease. However, gallstone ileus is not common in these patients. We report the case of a 70-year-old female with Crohn's disease who presented with gallstone ileus, and present a review of the literature. We discuss the association between gallstone ileus and Crohn's disease, and the treatment options for these patients. We emphasize the importance of including gallstone ileus in the differential diagnosis in patients presenting with intestinal obstruction, especially patients with long-standing Crohn's disease. We advocate the early utilization of computerized tomography to confirm the diagnosis, and prompt early surgical intervention.