Surgical treatment of esophageal perforations: the importance of a primary repair.

PURPOSE: The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis. METHODS: All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients. RESULTS: The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19). CONCLUSIONS: Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.

Incontinence in full-thickness rectal prolapse: low level of improvement after laparoscopic rectopexy.

AIM: The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse. METHOD: Eighty-five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self-administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery. RESULTS: After a mean follow-up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (-3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients' average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P < 0.0001) were significantly higher in patients suffering from postoperative incontinence. CONCLUSION: Despite some continence improvement in two-thirds of patients who underwent surgery for rectal prolapse, the level of improvement remained low in more than half of the patients.