Intratumor heterogeneity in colorectal cancer: Distribution of tumor suppressor gene variants with regard to patient lymph node status.

Intratumor heterogeneity (ITH) results from accumulation of somatic mutations in the fractions of successive cancer cell generations. We aimed to use deep sequencing to investigate ITH in colorectal tumors with particular emphasis on variants in oncogenes (ONC) and tumor suppressor genes (TSG). Samples were collected from 16 patients with colorectal cancer and negative or positive lymph node status (n = 8 each). We deep-sequenced a panel of 56 cancer-related genes in the central and peripheral locations of T3 size primary tumors and healthy mucosa. The central region of T3 tumors has a different frequency profile and composition of genetic variants. This mutation profile is capable of independently discriminating patients with different lymph node status (p = 0.028) in the central region. We noted an increasing number of mutations outside of the central region of the tumor and a higher number of mutations in tumors from node-positive patients. Unexpectedly, in the healthy mucosa, we identified somatic mutations with variant allele frequencies, characteristic not only of heterozygotes and homozygotes but also of other discrete peaks (e.g., around 10%, 20%), suggestive of clonal expansion of certain mutant alleles. We found differences in the distribution of variant allele frequencies in TSGs when comparing node-negative and node-positive tumors (p = 0.029), as well as central and peripheral regions (p = 0.00399). TSGs may play an important role in the escape of the tumor toward metastatic colonization.

The middle anorectal artery: A systematic review and meta-analysis of 880 patients/1905 pelvic sides.

The middle anorectal artery (MAA) is considered to supply the middle and lower parts of the rectum, however, its prevalence and point of origin vary across the literature. Clinical importance of the MAA becomes evident in the total mesorectal excision during the colorectal surgery of rectal cancer in both sexes, as well as interventional radiology procedures utilizing the prostatic vasculature in males. Major electronic medical databases were investigated for terms pertaining to the MAA and its associated variations. Compatible data regarding the artery's prevalence, laterality, origin, and distribution in both sexes was acquired. The risk of bias within the studies was assessed utilizing the AQUA tool. In total, 28 works (n = 880 patients/1905 pelvic sides) were included in this systematic review and meta-analysis, and their publication date ranged from 1897 until 2021. The overall pooled prevalence estimate for the MAA was 59.8% of the patients, and 55.2% of the pelvic sides studied. The vessel was identified more frequently in cadaveric pelvic sides evaluations (79.3%). The artery was found bilaterally more often (56.7%), and most commonly originated from the internal pudendal artery (50.3%). Anastomoses between the MAA and the other anorectal arteries were reported in 78.1%. The MAA is predominantly a present vessel, with various point of origin. Its direct clinical significance is yet to be discovered in larger study samples, providing more detailed and unified reports of its anatomical features, especially regarding its branches.

Does Implantation of an Artificial Soft Anal Band Provide an Opportunity for Improvement of Biopsychosocial Function in Patients with Severe Fecal Incontinence?

INTRODUCTION: Severe fecal incontinence describes a condition of complete loss of control over fundamental physiological functions and loss of abilities to fulfil psychosocial functions by the patients. The last-step procedure, that is, to restore hope for improvement of biopsychosocial functioning and quality of life determined by the patient's health status is implantation of an artificial anal sphincter. OBJECTIVE: The study was a comparative analysis of the effect of the employed surgical procedure upon the degree of defecation control and quality of life indices in its behavioral, mental, and social aspects prior to and 3, 6, and 12 months postoperatively. The analysis also included the effect of the patient's individual style of coping with stress and the functional outcome of the procedure. MATERIAL AND METHODS: The study included a group of 12 patients: 6 females and 6 males, aged from 36 to 60 years of life. The tools consisted of scoring systems that measured symptom intensity (FISI and Jorge and Wexner scale). In assessing the psychosocial functioning, the authors employed the Fecal Incontinence Quality of Life Scale (by Rockwood). The individual mode of coping with the disease was evaluated by using the CISS scale by Endler and Parker. CONCLUSIONS: The analysis of results demonstrated that the procedure of implanting an artificial anal sphincter affected the "continence" (up to 50-60% postoperatively) and led to improvement in psychosocial functioning in all its assessed aspects, i.e., lifestyle, employment of precautionary measures, depression, anxiety, and embarrassment. It was also noted that due to the specific character of the procedure (the necessity to operate an artificial implant), better mean results in assessment of the procedure functionality were achieved by patients presenting the goal-concentrated mode rather than emotions-concentrated mode of coping with the disease. Thus, it seems justified to state that assessment of biopsychological functioning may be a good criterion of the procedure effectiveness.

Cell therapy in surgical treatment of fistulas. Preliminary results.

Risk of recurrence after surgical treatment of a recurrent fistula is up to 50%. It has be known that more aggressive surgical treatment is associated with a high risk of anal sphincter damage and leads to incontinence. Several studies have been designed to elaborate minimally invasive treatment of rectovaginal and anal fistulas. The properties of Adipose-derived Stem Cells (ASC) significantly enhance a natural healing potency. Here, we present our experience with combined surgical and cell therapy in the treatment of fistulas. MATERIALS AND METHODS: Four patients were enrolled in our study after unsuccessful treatments in the past - patients 1-3 with rectovaginal fistulas including two women after graciloplasty, and patient 4 - a male with complex perianal fistula. Adipose tissue was obtained from subcutaneous tissue. ASCs were isolated, cultured up to 10+/-2 mln cells and injected into the walls of fistulas. Follow-up physical examination and anoscopy were performed at 1, 4, 8, and 12 weeks, 6 and 12 months after implantation. RESULTS: Up to 8 weeks after ASC implantation, symptoms of fistulas' tracts disappeared. At 8 weeks, in patients 1-3, communication between vaginal and rectal openings was closed and at 12-16 w. intestinal continuity was restored in patient 3 and 4. After a 6-month follow-up, the fistula tract of patient 4 was closed. Up to 12 m. after ASC implantation no recurrences or adverse events were observed. CONCLUSION: ASCs combined with surgical pre-treated fistula tracts were used in four patients. All of them were healed. This encouraging result needs further trials to evaluate the clinical efficiency and the cost-effectiveness ratio.

Video-Assisted Anal Fistula Treatment: Pros and Cons of This Minimally Invasive Method for Treatment of Perianal Fistulas.

PURPOSE: The purpose of this paper is to present results of a single-center, nonrandomized, prospective study of the video-assisted anal fistula treatment (VAAFT). METHODS: 68 consecutive patients with perianal fistulas were operated on using the VAAFT technique. 30 of the patients had simple fistulas, and 38 had complex fistulas. The mean follow-up time was 31 months. RESULTS: The overall healing rate was 54.41% (37 of the 68 patients healed with no recurrence during the follow-up period). The results varied depending on the type of fistula. The success rate for the group with simple fistulas was 73.3%, whereas it was only 39.47% for the group with complex fistulas. Female patients achieved higher healing rates for both simple (81.82% versus 68.42%) and complex fistulas (77.78% versus 27.59%). There were no major complications. CONCLUSIONS: The results of VAAFT vary greatly depending on the type of fistula. The procedure has some drawbacks due to the rigid construction of the fistuloscope and the diameter of the shaft. The electrocautery of the fistula tract from the inside can be insufficient to close wide tracts. However, low risk of complications permits repetition of the treatment until success is achieved. Careful selection of patients is advised.

Intraoperative neuromonitoring of hypogastric plexus branches during surgery for rectal cancer - preliminary report.

AIM: The aim of this study was to present our preliminary experience with intraoperative neuromonitoring during rectal resection. MATERIALS AND METHODS: We qualified 4 patients (2 women, 2 men; age 42 - 53 years) with rectal cancer for surgery with intraoperative neuromonitoring. In all patients, functional tests of the anorectal area were performed before surgery. Action potentials from the sphincter complex in response to nerve fiber stimulation were recorded with electrodes implanted before surgery. Moreover, we inserted a standard, 18FR Foley's urinary catheter to which a T-tube was connected to allow urine outflow and measurement of pressure changes in the bladder induced by detrusor contractions during stimulation. RESULTS: Setting up neuromonitoring prolonged surgery time by 30 to 40 minutes, or even by 60 to 80 minutes in the case of the first two patients. Neuromonitoring itself took additional 20 to 30 minutes during surgery. In all patients, we stimulated branches of the inferior hypogastric plexus in their anatomical position during dissection. In three patients, we evoked responses both from the bladder and the sphincter in all planes of stimulation. In one patient, there was no response from the left side of the bladder, and in the same patient, we observed symptoms of neurogenic bladder. CONCLUSIONS: Based on the available literature and our own experience, we state that monitoring of bladder pressure and electromyographic signals from rectal sphincters enables visualization and preservation of autonomic nervous system structures, both sympathetic and parasympathetic. Intraoperative signals seem to be correlated with clinical presentation and functional examinations after surgery. In order to objectify our results, it is necessary to perform functional examinations before and after surgery in a larger group of patients.

[Giant supernumerary parathyroid adenoma as a cause of persistent primary hyperparathyroidism in a patient with a multiglandular parathyroid disease].

Despite the significant progress that has been made in recent years in parathyroid imaging, improvements in surgical techniques and availability of surgical quality control based on intraoperative parathyroid hormone levels (PTH) assay, approximately 1-5% of patients undergoing surgery have state of persistent hyperparathyroidism. The most common causes of persistent hyperparathyroidism are: limited surgical experience, a failure to recognize multiglandular parathyroid disease, ectopic parathyroid adenoma location, insufficient range of resection of diseased parathyroid glands, parathyroid capsule tearing leading to parathyromathosis, as well as parathyroid cancer. In this clinical observation the case of a 52-years old man is described who underwent surgical removal of 2 parathyroid adenomas, and within few days he was found to have persistent hypercalcemia. After completing the diagnostic imaging and biochemical work-up that patient underwent bilateral neck re-exploration with removal of ectopic giant supernumerary parathyroid adenoma (60 mm in diameter and 22.8 g in weight) which was localized in the upper part of the posterior mediastinum, resulting in stable normocalcemia afterwards.

Geriatric Assessment as a qualification element for elective and emergency cholecystectomy in older patients.

BACKGROUND: Older patients experience a higher incidence of postoperative complications after cholecystectomy compared with younger patients. However, most studies have not considered patient frailty, particularly regarding emergency cholecystectomy. The aim of this prospective study was to evaluate outcomes in frail older patients eligible for elective and emergency cholecystectomy. METHODS: Preoperative Geriatric Assessment (GA) was performed in consecutive patients aged 65+ years, operated for biliary disease. The GA evaluated the functional, cognitive, comorbidity, depressive, nutritional, and polypharmacy status and patients with two or more abnormal domains were considered frail. Outcomes of interest were 30-day postoperative mortality, morbidity, and length of hospital stay (LOS). RESULTS: A total of 126 patients (median age 74; range 65-93 years) were included. There was no difference between elective frail and non-frail patients regarding postoperative mortality (0 %) and morbidity (6 % vs. 5 %; p = 0.76). LOS was not significantly longer in the frail group (5.6 vs. 4 days; p = 0.22). In the emergency-admitted patients, almost all complications occurred in the frail population (mortality 5 % vs. 0 %; morbidity 36.7 % vs. 3.3 %, compared with non-frail patients, respectively; p < 0.01) and LOS was significantly longer (10.3 (frail) vs. 6 days (non-frail);p = 0.03). Frail status was a significant independent predictive factor for postoperative complications in the emergency population, only (odds ratio: 3.4 (1.2-9.7); p = 0.02). CONCLUSIONS: Elective laparoscopic cholecystectomy is a safe and effective surgical technique also for older frail patients. In emergency settings, frail patients have significantly more complications and a longer LOS. However, the role of severity of frailty and the most reliable GA tools require further study. TRIAL REGISTRATION: ISRCTN14976998 (retrospectively registered).

Treatment of Acute Appendicitis in Geriatric Patients - Literature Review.

UNLABELLED: Demographic changes associated with the aging population mean that surgeons increasingly have contact and make decisions about treating patients from the oldest age groups. The aim of the study was to review the literature concerning the treatment of acute appendicitis in patients over the age of 60 years old. MATERIAL AND METHODS: A review of the literature published in the years 2000-2015 has been carried out using the PubMed database. The initial number of results corresponding to the query in English, "appendicitis (MeSH) AND elderly (MeSH)" was 260. Selection based on the titles, abstracts, and eventually whole articles, ultimately resulted in 11 papers concerning the treatment of appendicitis in patients above 60 years of age. RESULTS: Nine papers were retrospective and 2 were prospective. In total, the studies included 82,852 patients. Laparoscopic appendectomy was associated with a lower mortality rate, a smaller number of postoperative complications and a shorter length of hospital stay, which led to it being recommended by most authors. Four of the ten papers demonstrated that the patients who were qualified for laparoscopic surgery had less comorbidity and were in a lower ASA (American Society of Anaesthesiology) category. Antibiotic therapy as an independent method was assessed in one study in a group of elderly people, on a selected group of 26 patients, and its effectiveness was shown to be 70%. Most studies, however, are highly heterogeneous which significantly hindered comparisons. CONCLUSIONS: Currently, laparoscopic appendectomy seems to be the treatment of choice in the elderly with acute appendicitis. Antibiotic therapy, as an independent method of treatment of acute appendicitis, cannot currently be recommended. However, further, prospective, and better-designed studies are needed, involving a larger number of patients, and primarily dedicated to the elderly.

Differences in the Clinical Course of Acute Appendicitis in the Elderly in Comparison to Younger Population.

UNLABELLED: Acute appendicitis (AA) still remains the most common acute surgical abdominal emergency. Although 90% of cases occur in children and young adults, the incidence in the elderly amounts up to 10% and is constantly rising. The aim of the study was to assess the differences between clinical presentation in the elderly patients with AA compared to the younger patients. Additional aim was to assess the correlation between in-hospital time delays and patients' outcomes. MATERIAL AND METHODS: We conducted a retrospective analysis of medical data of 274 patients admitted to 3rd Department of General Surgery in Cracow between January 2011 and December 2013 due to AA. The elderly group comprised 23 patients aged 65 and above and the non-elderly group consisted of 251 patients. RESULTS: The groups did not differ in symptoms and their duration, type of surgery and its duration. However, time from admission to ED to the beginning of the procedure was significantly lower in the elderly group (575.56 vs 858.9 min; p=0.03). The elderly had longer hospital stay (6.08 vs 4.69 days; p=0.004). In the elderly group the perforation rate was close to reaching statistical significance (26.1% vs 12.4%; p=0.06). No mortality was noted in both groups and morbidity was slightly higher in elderly group (17.4% vs 10%; p=0.26). CONCLUSIONS: There was no difference in the clinical presentation between elderly and non-elderly patients group. However, elderly patients presented with a more progressed inflammation of the appendix. The hospital stay was longer in the elderly group, without any mortality and with higher rate of morbidity in this group. The length of the preoperative phase was significantly shorter, confirming the awareness of importance of time in the elderly patients with acute abdomen.

Graciloplasty, electrostimulation, electromyography. Clinical implications of electrophysiological phenomena in the neo-sphincter created from the gracilis muscle.

UNLABELLED: The aim of the study was to compare the electrophysiological phenomena occurring in the gracilis muscle, transposed into the pelvic floor during the graciloplasty procedure, subjected to continuous electrical stimulation by means of implanted stimulator, or regular stimulation by means of an external device, as well as the long-term functional results of the graciloplasty procedure. MATERIAL AND METHODS: A total of 27 patients were included in the analysis. The study group consisted of 7 patients after dynamic graciloplasty, 11 patients after graciloplasty followed by transrectal stimulation, 4 patients after graciloplasty with transcutaneous stimulation, and 5 patients after graciloplasty without any stimulation. All patients had a surface electromyographic examination of the transposed gracilis muscle performed, the signal for each patient was compared to the signal acquisited from a non-transposed gracilis in the same patient. In addition, each subject underwent a clinical operation results assessment, as well as an anorectal manometry examination. RESULTS: In the electromiographic examination, the mean frequency of motor units action potentials of the gracilis muscle in the thigh was 64 Hz, and in the muscle after transposition and stimulation period mean frequency was 62 Hz. There was no statistically significant difference in the frequency of action potentials before and after treatment in any of the analyzed groups, or between groups with different methods of stimulation (p> 0.05). We found a significant correlation between the clinical outcome of the procedure, and the average amplitude of the EMG signal from the transposed muscle, as well as between the amplitude of the EMG signal and the basal pressure in the anal canal in manometric examination. There were no significant correlations in the remaining manometric parameters. CONCLUSIONS: Despite the different methods of postoperative stimulation, including expensive implantable stimulators, there was no difference in the electrical activity between the transposed gracilis muscle, and the gracilis muscle left in situ. There was no signoficant advantage of the dynamic graciloplasty procedure over the graciloplasty with transanal or transcutaneous stimulation.

Gastrointestinal obstruction in patients previously treated for malignancies.

UNLABELLED: Bowel obstruction is a common condition in acute surgery. Among the patients, those with a history of cancer consist a particular group. Difficulties in preoperative diagnosis - whether obstruction is benign or malignant and limited treatment options in patients with reoccurrence or dissemination of the cancer are typical for this group. The aim of the study was to analyze causes of bowel obstruction in patients with history of radical treatment due to malignancy. MATERIAL AND METHODS: Patients with symptoms of bowel obstruction and history of radical treatment for malignancy who were operated in 2nd and 3rd Department of General Surgery JUCM between 2000 and 2014 were included into the study. The patients were divided into 2 groups based on type of mechanical bowel obstruction (group 1 - adhesions, group 2 - malignant process). RESULTS: 128 patients were included into the study - group 1: 67 (52.3%) and group 2: 61 (47.7%). In the second group bowel obstruction was caused by reoccurrence in 25 patients (40.98%) and dissemination in 36 (59.02%). The mean time between onset of the symptoms of bowel obstruction and the end of treatment for the cancer was 3.7 and 4.4 years, respectively in group 1 and 2 (p>0.05). Median time between onset of the symptoms and admission to Emergency Department was significantly longer in patients with malignant bowel obstruction compared to those with adhesions (11.6 ±17.8 days vs 5.1 ± 6.9 days, p=0.01). Considering type of surgery due to bowel obstruction, in first group in most patients (69.2%) bowel resection was not necessary and in the second group creation of jejuno-, ileo- or colostomy was the most common procedure. Morbidity was significantly higher in second group (45.9% vs 28.26%, p<0.05) but there was no difference in mortality (26% vs 24%, p>0.05). In both groups the most common localization of primary malignancy was colon. CONCLUSIONS: In analyzed group of patients frequency of bowel obstruction caused by adhesions and malignancy was similar. However, in patients with bowel obstruction caused by malignancy morbidity was significantly higher and duration of symptoms was longer. There was no diagnostic procedure which would allow to differentiate the cause of bowel obstruction preoperatively and the diagnosis was made during the operation.

Can surface electromyography improve surgery planning? Electromyographic assessment and intraoperative verification of the nerve bundle entry point location of the gracilis muscle.

PURPOSE: To verify the precision of surface electromyography (sEMG) in locating the innervation zone of the gracilis muscle, by comparing the location of the IZ estimated by means of sEMG with in vivo location of the nerve bundle entry point in patients before graciloplasty procedure due to fecal incontinence. METHODS: Nine patients who qualified for the graciloplasty procedure underwent sEMG on both gracilis muscle before their operations. During surgery the nerve bundle was identified by means of electrical stimulation. The distance between the proximal attachment and the nerve entry point into the muscle's body was measured. Both measurements (sEMG and in vivo identification) were compared for each subject. RESULTS: On average, the IZ was located 65.5mm from the proximal attachment. The mean difference in location of the innervation zones in each individual was 10±9.7mm, maximal - 30mm, the difference being statistically significant (p=0.017). It was intraoperatively confirmed, that the nerve entered the muscle an average of 62mm from the proximal attachment. The largest difference between the EMG IZ estimation and nerve bundle entry point was 5mm (mean difference 2.8mm, p=0.767). CONCLUSION: Preoperative surface electromyography of both gracilis muscles is a safe, precise and reliable method of assessing the location of the innervation zones of the gracilis muscles. The asymmetry of the IZ location in left and right muscles may be important in context of technical aspects of the graciloplasty procedure.

Dynamic versus Adynamic Graciloplasty in Treatment of End-Stage Fecal Incontinence: Is the Implantation of the Pacemaker Really Necessary? 12-Month Follow-Up in a Clinical, Physiological, and Functional Study.

Purpose. The aim of the study is to compare functional results of end-stage fecal incontinence treatment with dynamic graciloplasty and adynamic graciloplasty augmented with transanal conditioning of the transposed muscle. Methods. A total of 20 patients were qualified for graciloplasty procedure due to end-stage fecal incontinence. 7 patients underwent dynamic graciloplasty (DGP), whereas 13 patients were treated with adynamic graciloplasty, with transanal stimulation in the postoperative period (AGP). Clinical, functional, and quality of life assessments were performed 3, 6, and 12 months after the procedures. Results. There were no intraoperative or early postoperative complications. The detachment of gracilis muscle tendon was observed in one patient in DGP group and two in AGP group. There was a significant improvement of Fecal Incontinence Quality of Life (FIQL) and Fecal Incontinence Severity Index (FISI) scores in both groups 12 months after procedure. Anorectal manometry showed improvement regarding basal and squeeze pressures in both groups, with significantly better squeeze pressures in AGP group. Conclusions. The functional effects in the DGP and AGP groups were similar. Significantly lower price of the procedure and avoidance of implant-related complication risk suggest the attractiveness of the AGP method augmented by transanal stimulation.

Efficacy of lift (ligation of intersphincteric fistula tract) for complex and recurrent anal fistulas--a single-center experience and a review of the literature.

UNLABELLED: Ligation of intersphincteric fistula tract in treatment of anal fistulas (LIFT) is being said to have satisfactory results in short and long follow up, with low risk of complications. This study was designed to evaluate the results in patients with complex and recurrent fistulas in comparison with simple transsphincteric anal fistulas. The aim of the study was to present a single-center experience in LIFT procedure in treatment of both simple and complex anal fistulas, including recurrent fistulas, in comparison with a review of current literature. MATERIAL AND METHODS: A series of 17 patients were qualified to LIFT procedure. 5 patients were treated for simple transsphincteric, 6 for complex fistulas, 6 with fistulas recurrent after fistulotomy. Median age was 47, most of the patients were male (16/17). Mean follow up was 11 months. RESULTS: Mean operating time was 55 minutes counting from surgical site disinfection to final dressing of the wound. Of the 17 patients the overall success rate was 53%. As expected, best results were achieved in patients with simple fistulas (80% success rate), then complex (50%), and recurrent fistulas (only 33%). There were no early nor late complications of the surgery. CONCLUSION: As expected, in simple transsphincteric fistulas the results were satisfactory, taking into account low complication rate. Complex and recurrent fistulas seem to be risk factors of LIFT failure. The results are consistent with data published by other authors, based on the review of the current literature, and it seems there is still room for improvement, so further research is required.

Quality of Life Aspects Determining The-Bio-Psycho-Social Functioning of Patients in The-Perspective of a Planned Extensive Sphincter's Repair Procedure.

UNLABELLED: Damage to the sphincter, regardless of its pathogenesis, consists in the impossibility to control the physiology, or the so-called faecal incontinence. This implies changes in the whole bio-psycho-social functioning of the patients, and thus affects the satisfaction with their quality of life, conditioned by their health status. The problem affects around 5 to 7% of the population. Often enough, the only hope for those patients are repair procedures of the sphincter mechanism. The aim of the study was to evaluate key aspects of quality of life which determine the psycho-social status of patients with endogenous or iatrogenic sphincter damage in the perspective of a planned extensive sphincter's repair procedure. MATERIAL AND METHODS: The study group consisted of 52 people, 26 women and 26 men, aged 19-72. The scale by Rockwood--Fecal Incontinency Quality of Life--was used as the basic research tool which evaluates the quality of life in four aspects: 1/behavioral (Lifestyle) 2/cognitive (Coping) 3/emotional (Depression) 4/overall self-assessment (Embarrasment). The degree of incontinence was determined based on point scales of Jorge Wexner (JW scale) and the Fecal Incontinenece Severity Index (FISI scale). Structured diagnostic interview was also used in the study. RESULTS: The results show that lack of control over the basic physiological functions disintegrates the quality of life in all evaluated aspects related to somatic, psychological and social functioning. FIQL: Lifestyle (LS) - 1.96 pts Coping (C) - 1.67 pts Depression (D) - 2.1 pts Embarrasment (E) - 1.79 pts Conclusions. The FIQL results presented explain the fact that among 52 patients followed, 50 decided to conduct extensive reconstructive procedures, although the results are not statistically optimistic and the risk of complications is relatively high.

Laparoscopically implanted system for stimulation of the hypogastric plexus induces colonic motility, defecation, and micturition: experimental study.

BACKGROUND: Modulation of the enteric nervous system seems to be promising in several functional colorectal disorders for which targeted, causal treatment methods do not exist. However, sacral nerve stimulation can induce undesirable muscle contraction or paresthesia. Therefore, we have developed a laparoscopic technique for implanting a neural electrode, placed directly over the pelvic autonomic nerve plexus. The aim of this experimental study was to evaluate the effect of stimulating the hypogastric plexus and pelvic nerves on inducing distal colon contraction, defecation, and micturition. METHOD: A total of 10 white, male healthy pigs (25-30 kg) were subjected to the laparoscopic implantation of the electrode and the stimulator. In the third and fourth weeks postimplantation, the efficacy of the acute and chronic stimulation to induce defecation was evaluated. RESULTS: The average operative time was 105 minutes (85-150 minutes). In all pigs, acute stimulation activated induced defecation, every second day, every time on demand, with an average delay of 139.7 s. Micturition was induced incidentally. Acute or chronic stimulation did not cause any harm, pain, or suffering to the animals. No adverse effects of the stimulation were observed, and no septic complications or macroscopic fibrosis around the electrodes were found on autopsy. CONCLUSION: Hypogastric plexus stimulation can be a useful and safe option of distal colon contraction, defecation, and micturition. However, the efficacy of the stimulation was observed for a relatively short period of time, and it is not known if it will be sustained for a longer duration.

Transanal endoscopic microsurgery combined with endoscopic posterior mesorectum resection in the treatment of patients with T1 rectal cancer - 3-year results.

INTRODUCTION: Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 rectal cancer (RC). However, it is associated with an increased rate of local recurrence in comparison with extended resection. In most cases this failure is linked to inappropriate case selection and the presence of clinically non-detectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in a minimally invasive way, which in turn can help in adequate tumor staging. AIM: To evaluate the long-term clinical results and influence of combined TEM and EPMR treatment on the anorectal functions. MATERIAL AND METHODS: Ten consecutive patients with T1 RC were operated on using TEM and EPMR as a two-stage procedure between 2007 and 2009. RESULTS: After a median follow-up of 42.6 (range: 36-80) months, none of our patients complained of symptoms of incontinence apart from one female patient with gas incontinence diagnosed preoperatively. There was no statistically significant difference in basal anal pressure, squeeze anal pressure, high pressure zone length or fecal continence assessed using the Fecal Incontinence Severity Index before and in follow-up months after the procedure. Postoperative morbidity consisted of one hematoma formation and one male patient complaining about sexual dysfunction until 6 months postoperatively. There was no evidence of locoregional recurrence. CONCLUSIONS: Endoscopic posterior mesorectal resection in combination with TEM appears to be safe, feasible and with no impact on the basic anorectal functions in the 3-year follow-up.

VAAFT: a new minimally invasive method in the diagnostics and treatment of anal fistulas--initial results.

UNLABELLED: The aim of the study was to present our own experience in the treatment of anal fistulas by means of VAAFT (Video-Assisted Anal Fistula Treatment). MATERIAL AND METHODS: Twenty patients were qualified for the VAAFT procedure. All were subjected to diagnostics. Two patients after the diagnostic stage underwent classical fistula surgery. The remaining 18 patients were subjected to the full procedure (diagnostic fistuloscopy, supply of the internal ostium, and coagulation of the fistula canal). The mean observation period was 10 months. RESULTS: In most cases the trans-sphincter fistula was observed during the diagnostic phase, including three with additional fluid compartments. There was one intersphincteric fistula. Considering the 18 patients subjected to the full VAAFT procedure the internal ostium was supplied by means of an advancement flap in 3 cases, while in 11 by means of a mattress suture, including one with additional tissue glue. In 4 cases the internal ostium was tightly covered by mucosa. Surgical complications were not observed during the procedure. During further observation a permanent fistula was observed in 4 (22%) patients, and in two (17%), recurrence of anal fistula. In the remaining 12 patients one observed healing without fistula recurrence. Complications were not observed, including stool and gas control deterioration (based on the FISI scoring). CONCLUSIONS: The VAAFT method does not affect sphincter efficiency, no intra- and postoperative complications were observed. As compared to other minimally invasive procedures a comparable recovery rate is observed without the risk of incontinence. It is the only method enabling the intraoperative identification of the internal ostium and fistula canal under visual control. Initial optimistic results require further investigations on a larger group of patients.