The importance of compression time in stapled hemorrhoidopexy: is patience a virtue?

Purpose: The aim of this study was to evaluate whether longer compression time before firing the stapler reduced the postoperative complications related to staple line formation in stapled hemorrhoidopexy. Methods: This retrospective case-control study was conducted at a colorectal-anal specialty hospital. Consecutive patients with grade III and IV hemorrhoids who underwent stapled hemorrhoidopexy between January 2016 and November 2019 were included. According to the compression time, patients were assigned to the long compression time group (2 minutes) or the typical compression time group (30 seconds). The primary outcome measure was incidence of staple line complications such as dehiscence, bleeding, and stenosis. Results: A total of 348 patients treated with stapled hemorrhoidopexy were evaluated. Seventy-three and 275 patients were included in the long compression time group and the typical compression time group, respectively. No significant differences were observed in patient characteristics between the groups. However, additional procedures were performed more frequently in the typical compression time group (78.1% vs. 92.0%, P=0.001). Bleeding occurred more frequently in the typical compression time group (1.4% vs. 8.4%, P=0.030). The rates of dehiscence and stenosis were not significantly different between the groups. Fecal urgency developed more frequently in the typical compression time group (0% vs. 5.1%, P=0.040). In logistic regression analysis, typical compression time (30 seconds) was the only risk factor for bleeding (odds ratio, 8.496; P=0.040). Conclusion: Longer compression time was associated with a decreased incidence of postoperative bleeding after stapled hemorrhoidopexy.

Standardized Method of the Thiersch Operation for the Treatment of Fecal Incontinence.

BACKGROUND: Conventionally, the Thiersch operation has typically involved blind positioning of the sling, and sling tension is subjectively based on a rule-of-thumb estimate. The aim of this study was to describe standardized methods for performing the Thiersch operation. METHODS: Seventeen patients with fecal incontinence underwent the calibrated method of the Thiersch procedure. As an encircling sling, a 6-mm-wide silastic tube was used. Through 4 minimal perianal skin incisions, the sling was placed proximal to the anal skin 3 cm from the anal verge and 4 cm in depth. The circumference of the sling was 10 cm in length. Results were assessed by clinical responses and by comparing pre- and postoperative Wexner scores. The data were collected retrospectively. RESULTS: The median follow-up period was 9 months (range 6-19). In 16 out of 17 fecal incontinence patients (94.1%), the median Wexner incontinence score was 0 (range 0-3) postoperatively. Localized sepsis developed in three cases (17.7%, 3/17), which were controlled with drainage and antibiotics. Fecal impaction occurred in one case (5.9%, 1/17). There was no removal or breakage of the inserted sling. CONCLUSIONS: The elasticity of the silastic tube reduced the incidence of sling breakage. According to the standardized method, the sling was placed external to the external anal sphincter muscle and at the junction of the external anal sphincter muscle and puborectalis muscle. Fecal incontinence was controlled effectively, and the incidence of fecal impaction was negligible. High reproducibility was observed with this method.

High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique.

BACKGROUND: Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-preserving operation for anal fistulas. Although it has advantages in preserving continence after surgery, it is difficult to perform owing to the narrow field of view. We performed a modified surgical procedure based on the LIFT to overcome these drawbacks. MATERIALS AND METHODS: Twenty-eight patients who were scheduled to undergo high ligation of the anal fistula tract by the lateral approach for the treatment of transsphincteric anal fistulas were prospectively studied. Instead of making a new stab incision on the intersphincteric groove, we dissected along the fistula tract from the external opening until the intersphincteric space appeared. The fistula tract was then ligated close to the internal anal sphincter with absorbable sutures, and the distal part of the ligation was cut off. A cored-out wound was left open for drainage. RESULTS: The median follow-up was 16 months (range, 8-27 months). Of the 28 patients, 19 (68%) had simple transsphincteric fistulas and 9 (32%) had complex transsphincteric fistulas. Successful fistula closure was achieved in 21 patients (75%), with a median healing time of 4 weeks (range, 3-7 weeks). None of the patients complained of any incontinence symptoms after the procedure. Of the seven patients (25%) who failed to heal successfully, two (7%) did not heal up to 2 months after surgery and five (18%) experienced recurrence after complete healing. CONCLUSION: High ligation of the anal fistula tract by lateral approach may be a useful sphincter-sparing procedure for transsphincteric anal fistulas.

Comparison of skin incisions used for open lateral internal sphincterotomies--radial versus circumferential incisions: a retrospective cohort study.

INTRODUCTION: Lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment, commonly used in patients with chronic anal fissures (CAFs). Although LIS is a simple surgical technique, it may cause several complications. Open LIS is usually performed through an incision made in the intersphincteric groove; radial or circumferential incisions, used according to the surgeon's preference. However, differences in clinical outcomes and wound healing, based on type of skin incision, are unclear. We investigated incision site wound healing and other clinical outcomes, after open LIS, according to the type of skin incision employed. METHODS: We retrospectively reviewed the data of the electronic medical records of 602 patients who underwent open LIS for CAFs between March 2005 and February 2010 at Yang Hospital, Seoul, Korea. RESULTS: Of the 602 patients, 298 patients received radial incisions and 304 received circumferential incisions. Circumferential incisions of the anus reduced the wound healing time compared to radial incisions (19.1 vs. 24.0 days, p < 0.001). There were no significant differences between the groups in wound complications such as perianal abscess, fistula, or cellulitis. Clinical outcomes including recurrence, persistence of fissures, and continence problems were also similar between the groups. CONCLUSIONS: Our study shows that circumferential skin incisions, during LIS, are associated with shorter healing times than radial incisions.

The use of a staged drainage seton for the treatment of anal fistulae or fistulous abscesses.

PURPOSE: The aim of this retrospective study was to evaluate the rate of recurrence and incontinence after the treatment of fistulae or fistulous abscesses by using the staged drainage seton method. METHODS: According to the condition, a drainage seton alone or a drainage seton combined with internal opening (IO) closure and relocation of the seton was used. After a period of time, the seton was changed with 3-0 nylon; then, after another period of time, the authors terminated the treatment by removing the 3-0 nylon. Telephone interviews were used for follow-up. The following were evaluated: the relationship between the type of fistula and recurrence; the relationship between the type of fistula and the period of treatment; the relationship between the recurrence and presence of abscess; the relationship between IO closure and recurrence; the relationship between the period of seton change and recurrence; reported continence for flatus, liquid stool, and solid stool. RESULTS: The recurrence rate of fistulae or suppuration was 6.5%, but for cases of horseshoe extension, the recurrence rate was 57.1%. The rate of recurrence was related to the type of fistula (P = 0.001). Incontinence developed in 3.8% of the cases. No statistically significant relationship was found between the rate of recurrence and the presence of an abscess or between the closure of the IO and the period of seton change or removal. CONCLUSION: In the treatment of anal fistulae or fistulous abscesses, the use of a staged drainage seton can reduce the rate of recurrence and incontinence.

Is There Any Relationship between the Chronicity of Chronic Anal Fissure and Endothelin-1?

PURPOSE: Many kinds of substances are produced on vascular endothelial activation. The aim of this study is to confirm an increase in Endothelin-1 (ET-1), the most potent vasoconstrictor, which is produced by endothelial activation, in patients with chronic anal fissure and to infer the relationship between ET-1 and anal fissure chronicity. METHODS: The study groups are divided into three different groups with 30 subjects each. Group 1 is comprised of healthy volunteers, group 2 of chronic anal fissure patients, and Group 3 of patients with higher than 3rd degree hemorrhoids. Blood samples were taken to measure the ET-1 levels in subject's serum and to compare the results with those for the control groups. RESULTS: Among the 90 subjects, 38 were male, and 52 were female. The average age was 36.8. The average ET-1 level marked 1.47 ± 0.78 pg/mL for male subjects and 1.16 ± 0.47 pg/mL for female subjects (P = 0.02). The average ET-1 level in the patient groups is as follow: 1.21 ± 0.44 pg/mL in group 1, 1.46 ± 0.83 pg/mL in group 2, and 1.20 ± 0.56 pg/mL in group 3 (P = 0.14). CONCLUSION: Group 2, the chronic anal fissure patient group, showed a higher ET-1 level than groups 1 and 3, the control group and the hemorrhoid patient group, but this difference had no statistical significance.

Robot-assisted gastrectomy with lymph node dissection for gastric cancer: lessons learned from an initial 100 consecutive procedures.

OBJECTIVE: To evaluate the technical feasibility, effectiveness, and safety of robot-assisted gastrectomy (RAG) with lymphadenectomy, using the da Vinci system through analyses of our initial series of 100 consecutive patients. SUMMARY BACKGROUND DATA: The application of robotic surgery was proven to be one of the best cutting-edge technologies for successful minimally invasive surgery by providing solutions to the many drawbacks of laparoscopic surgery, yet few reports have studied robotic surgery in gastric cancer. METHODS: A review of a prospectively designed database at our institute from July 2005 to October 2007 revealed a series of 100 consecutive RAG patients with a preoperative diagnosis of early gastric cancer. Clinicopathologic characteristics and surgical outcomes were analyzed. RESULTS: All operations were performed successfully without open or laparoscopic conversion. There were 33 total gastrectomies and 67 subtotal gastrectomies with D1+beta or extended lymphadenectomy (D2). The mean total operation time and console time were 231 and 150 minutes, respectively. There were 13 postoperative morbidities and 1 postoperative mortality. The first flatus was noted on postoperative day 2.9, soft diet was started on postoperative day 4.2, and the mean postoperative hospital stay was 7.8 days. Although all patients were diagnosed as early gastric cancer preoperatively, the final pathology report revealed that 19 patients exhibited a depth deeper than T2. The mean number of retrieved lymph nodes was 36.7 (range, 11-83). None of the specimens showed microscopic tumor involvement in the resection line. CONCLUSIONS: This study demonstrated that RAG with lymphadenectomy can be applied safely and effectively for patients with gastric cancer.

Role of robotic gastrectomy using da Vinci system compared with laparoscopic gastrectomy: initial experience of 20 consecutive cases.

BACKGROUND: Robotic surgery was invented to overcome the demerits of laparoscopic surgery. However, the role of robotic surgery in gastrectomy has rarely been reported. This study aimed to evaluate the use of robot-assisted distal subtotal gastrectomy to facilitate surgical training for gastric cancer. METHODS: Twenty gastric cancer patients who underwent robotic gastrectomy from July 2005 to November 2006 were compared with 20 initial patients who underwent laparoscopic subtotal gastrectomy from May 2003 to August 2003 and 20 recent patients who underwent laparoscopic subtotal gastrectomy during the same period as the 20 robotic gastrectomy procedures by the same surgeon. RESULT: All 60 patients underwent subtotal gastrectomies with gastroduodenostomy without open or laparoscopic conversion. Operation time for robotic gastrectomy, initial laparoscopic gastrectomy, and recent laparoscopic gastrectomy was 230 min (range 171-312 min), 289.5 min (range 190-450 min), and 134.1 min (range 90-260 min). The number of retrieved lymph nodes was 35.3 +/- 10.5, 31.5 +/- 17.1, and 42.7 +/- 14.9, respectively. Hospital stay was 5.7, 7.7, and 6.2 days, respectively. Postoperative complication occurred in two patients in recent laparoscopic gastrectomy and one patient each in robotic and initial laparoscopic gastrectomy. CONCLUSION: In this context, it could be assumed that experienced laparoscopic surgeons could perform robotic gastrectomy with a certain level of skill, even in initial series.