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.

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.

Botulinum toxin A for the treatment of chronic anal fissure.

Since its introduction for the treatment of strabismus, botulinum toxin (BoNT) has been increasingly used in the treatment of several disorders with excessive or inappropriate muscle contractions. The therapeutic effects of BoNT occur through the temporary chemodenervation caused by the injection into the local target muscle or skin. Modulation of muscle relaxation may be achieved by varying the dose of BoNT solution injected; most adverse effects are transient. Indeed, botulinum neurotoxin has been used to selectively weaken the internal anal sphincter as a treatment for chronic anal fissure in several randomized, controlled trials and open-label studies. The use of botulinum neurotoxin seems to be an effective and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence.