Botulinum toxin for chronic anal fissure after biliopancreatic diversion for morbid obesity.

AIM: To study the effect of botulinum toxin in patients with chronic anal fissure after biliopancreatic diversion (BPD) for severe obesity. METHODS: Fifty-nine symptomatic adults with chronic anal fissure developed after BPD were enrolled in an open label study. The outcome was evaluated clinically and by comparing the pressure of the anal sphincters before and after treatment. All data were analyzed in univariate and multivariate analysis. RESULTS: Two months after treatment, 65.4% of the patients had a healing scar. Only one patient had mild incontinence to flatus that lasted 3 wk after treatment, but this disappeared spontaneously. In the multivariate analysis of the data, two registered months after the treatment, sex (P = 0.01), baseline resting anal pressure (P = 0.02) and resting anal pressure 2 mo after treatment (P < 0.0001) were significantly related to healing rate. CONCLUSION: Botulinum toxin, despite worse results than in non-obese individuals, appears the best alternative to surgery for this group of patients with a high risk of incontinence.

Surgical treatment of anal stenosis.

Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer.

BACKGROUND AND AIMS: Sphincter-saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end-to-end and end-to-side anastomosis after anterior resection for T1-T2 rectal cancer. METHODS: During the study period, a total of 298 rectal cancer patients were treated. Patients with T1-T2 rectal cancer (i.e., tumor level < or =15 cm from the anal verge) fit for surgery were asked to participate in the study. Patients were randomized to receive either an end-to-end anastomosis or an end-to-side anastomosis using the left colon. Surgical results and complications were recorded. RESULTS: Seventy-seven patients were randomized. Thirty-seven end-to-end anastomoses and 40 end-to-side anastomoses were performed. Anastomotic leakage after end-to-end anastomosis was 29.2%, while after end-to-side anastomosis was 5% (P = 0.005). In the end-to-end group 11 patients had anastomotic leaks: nine patients needed a re-intervention with colostomy creation subsequently closed in seven cases. Two patients of the end-to-side group experienced anastomotic leakage and were successfully treated conservatively. CONCLUSIONS: Regarding postoperative surgical complications, end-to-side anastomosis is a safe procedure.

Relief by botulinum toxin of lower urinary tract symptoms owing to benign prostatic hyperplasia: early and long-term results.

OBJECTIVES: To present a comprehensive experience with intraprostatic botulinum toxin (BT) injection in men with symptomatic benign prostatic hyperplasia (BPH). METHODS: In this open-label study using an outpatient setting, 77 men with BPH received 200 intraprostatic BT A units (Botox) using an ultrasound-guided transperineal approach. We evaluated the American Urological Association (AUA) score, serum prostate-specific antigen (PSA), prostatic volume, residual volume, and peak urinary flow rates. The primary endpoint was symptomatic improvement after treatment, as measured by means of AUA score and peak urinary flow rates. The secondary endpoint was the evaluation of prostatic volume, serum PSA, and residual urinary volume. RESULTS: No significant local effects occurred. At their 1-month evaluation, 41 patients had subjective symptomatic relief. Compared with baseline values, AUA score was reduced from 24.1 +/- 4.6 to 12.6 +/- 2.9 (P = .00001), and serum PSA from 6.2 +/- 1.7 to 4.8 +/- 1.0 ng/mL (P = .03). At the same time, prostatic volume and residual urine volume were reduced by 12.7% and 12.8%, respectively, and mean peak urinary flow rate increased (P = .01). At 2 months' evaluation, 55 patients had subjective symptomatic relief. AUA score was reduced by 63.9% (P = .00001) compared with baseline values. In the same patients, serum PSA, prostatic volume, and residual urine volume were reduced by 51.6% (P = .00001), 42.8% (P = .00001), and 55.9% (P = .002), respectively, and mean peak urinary flow rate increased significantly. CONCLUSIONS: Intraprostatic BT seems to be a promising approach to the treatment of BPH. It is safe, effective, well-tolerated, and not related to the patient's willingness to complete treatment.

Duplex ultrasound evaluation of testicular perfusion after tension-free inguinal hernia repair: results of a prospective study.

BACKGROUND/AIMS: Open tension-free techniques of hernia repair using synthetic meshes are a well-accepted practice with an excellent patient comfort and a low recurrence rate. Otherwise, the influence of the resulting fibrosis on testicular perfusion is still unclear. In this study, the effect of prosthetic materials on testicular perfusion was evaluated using Duplex ultrasonography. METHODOLOGY: Twenty-four patients participated in this prospective study. A total of 26 procedures were performed under general anaesthesia. All patients underwent standardized scrotal ultrasound study and Duplex imaging preoperatively, 1, 3 and 9 months after the procedure. Scrotal volume, vein diameters and modifications of arterial blood flow, evaluated by the acceleration index (AI), of the funicular and peritesticular vessels were measured. RESULTS: No statistically significant differences were found between preoperative and postoperative measurements which included testicular blood flow parameters and testicular volume. Moreover, in some cases, a testicular flow improvement was detected after the operation. Furthermore the side of the hernia and the position of the mesh slit (lateral or upper) to allow the passage of cord structures did not influence the results. CONCLUSIONS: So far there is no evidence for a significant impairment of funicular structures after open hernia repair using tension free techniques.

Laparoscopic rectal resection with intraoperative radiotherapy in locally advanced cancer: preliminary results.

Carcinoma of the rectum is a common malignancy, especially in developed countries. The main stay of the therapy for rectal cancer is radical surgery. Total mesorectal excision has emerged as the surgical technique that can substantially reduce local recurrences. The laparoscopic approach does not seem to entail any oncologic disadvantages. Radiotherapy (RT) alone is capable of eradicating some localized rectal tumors while its effect on larger tumors is limited by normal tissue tolerance, tumor sensitivity and microscopic spread beyond the primary site. Preoperative chemoradiation has potential advantages. The rationale for combining cytotoxic agents and RT is based on the ability of some drugs to act as an enhancer of RT. Preoperative chemoradiation can potentially downstage tumors to facilitate surgery, reduce the risk of tumor seeding, problems with hypoxia which is increased postoperatively, allowing more optimal tumor cell kill for equivalent doses compared to postoperative radiotherapy. The addition of radiation to surgery has been successfully used in many disease sites. In the intraoperative radiotherapy (IOERT), a high dose to the area of highest risk for tumor cell persistence is delivered while dose-limiting structures such as small bowel, bladder, or ureters can be mechanically excluded. Our preliminary experience shows that laparoscopic rectal resection with IOERT is not only feasible, but associates oncologic radical treatment with important advantages of laparoscopic approach.

Experience with type A botulinum toxin for treatment of outlet-type constipation.

BACKGROUND: Puborectalis syndrome remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, laxatives, enemas, biofeedback training, and surgery. These often were tried sequentially and had conflicting or even disappointing results. We investigated the efficacy of injections of botulinum toxin in improving rectal emptying in patients with defecatory disorders involving spastic pelvic-floor muscles. METHODS: Twenty-four consecutive patients with chronic outlet obstruction constipation resulting from puborectalis syndrome were included in the study. The patients were treated with 60 units of type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance. RESULTS: At 2 months, evaluation inspection revealed a symptomatic improvement in 19 patients. Anorectal manometry demonstrated decreased tone during straining from 98 +/- 24 to 56 +/- 20 mmHg at a 1-month evaluation (p < 0.01) and 56 +/- 29 mmHg at a 2-month follow-up (p < 0.01). Pressure during straining was lower than resting anal pressure at the same time in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 98 +/- 9 degrees to 121 +/- 15 degrees (p < 0.01). CONCLUSIONS: Botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective, especially with the use of the ultrasonographic guidance that accounts for a more precise injection and consequently better long-term results. Otherwise, given the limited effect of the toxin, repeated injections may be necessary to maintain the clinical improvement.