An imaginary cuboid: chest, abdomen, vertebral column and perineum, different parts of the same whole in the harmonic functioning of the pelvic floor

Effect of lidocaine on postoperative analgesia of endoscopic rubber band ligation combined with injection sclerotherapy for treatment of internal hemorrhoids: A retrospective study (with video)

BACKGROUND AND STUDY AIMS

Endoscopic minimally invasive treatment of internal hemorrhoids may cause postoperative pain. The aim of the study is to investigate the analgesic effect of lidocaine plus lauromacrogol on postoperative pain caused by endoscopic rubber band ligation (ERBL) combined with injection sclerotherapy (IS) for internal hemorrhoids treatment.

PATIENTS AND METHODS

Clinical data of grade Ⅲ internal hemorrhoids patients who underwent ERBL combined with IS in department of Digestive Medicine, Shenzhen Hospital of Southern Medical University, were retrospectively analyzed. According to difference in the composition of sclerosing solution, the patients were divided into control group (lauromacrogol group, 46 patients) and study group (lidocaine plus lauromacrogol group, 20 patients). Postoperative pain (quantized by Visual Analogue Scale, VAS), pain relief time and postoperative adverse reactions were compared. The therapeutic effect was followed up 1 month after operation.

RESULTS

VAS of postoperative pain was 0.80 ± 0.42 points and pain relief time was 0.90 ± 0.56 days in the study group, while VAS of postoperative pain was 4.11 ± 1.37 points and pain relief time was 2.57 ± 0.83 days in the control group, there was statistical difference between them (P < 0.05). There was no significant difference in the incidence of postoperative adverse reactions and follow-up therapeutic effect between the control group and the study group.

CONCLUSION

Lidocaine plus lauromacrogol is useful for pain alleviation on ERBL combined with IS for internal hemorrhoids treatment because of its convenient procedure, low adverse reaction incidence and good therapeutic effect, which is worthy of promotion.

Modified whitehead hemorrhoidectomy versus partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids: A retrospective analysis

Background

Grade IV circular hemorrhoids are difficult to treat. We aim to describe the modified whitehead hemorrhoidectomy procedure and to assess the effectiveness and safety of this procedure for grade IV circular hemorrhoid patients.

Methods

Patients with grade Ⅳ circular hemorrhoids who underwent modified Whitehead hemorrhoidectomy and partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids were retrospectively reviewed. Clinical data were extracted from the database at our institution, and long-term postoperative complications were assessed through repeated outpatient examinations and telephonic communication.

Results

A total of 205 patients were included in this study. The mean operative time was 59.2 ± 13.8 min. The average hospital stay was 4.6 ± 1.0 days. For postoperative complications, 66 (32.2%) patients had urinary retention, 10 (4.9%) patients had a sense of incomplete rectal emptying, 5 (2.4%) patients had anal incontinence, and 6 (2.9%) patients had wound infection. For long-term postoperative complications, 3 (1.5%) patients experienced mild to moderate anal stricture, 2 (1%) patients experienced mucosal ectropion, they all had smooth recoveries, and none of them needed secondary surgery. None of these patients had a hemorrhoid recurrence. A total of 205 patients who received modified Whitehead hemorrhoidectomy and 161 who received partial hemorrhoidectomy were included. There were no residual hemorrhoids in patients who received modified Whitehead hemorrhoidectomy, and none had hemorrhoid recurrence. Fifty-eight patients who received partial hemorrhoidectomy had hemorrhoidal residues, and 19 patients experienced hemorrhoid recurrence. After modified Whitehead hemorrhoidectomy, 3 patients developed anal stenosis, and 2 had mucosal ectropion. Four patients developed anal stricture after partial hemorrhoidectomy, and none had mucosal ectropion. They all had smooth recoveries, and none of them needed a secondary surgery. For the mean duration of surgery, postoperative bleeding, postoperative pain, wound infection, sense of incomplete rectal emptying, anal incontinence, and urinary retention, no statistically significant differences were found between the two groups.

Conclusions

Compared with partial hemorrhoidectomy, modified whitehead hemorrhoidectomy is an effective and safe surgical procedure and does not significantly increase the risk of anal stenosis and mucosal ectropion for grade IV circular hemorrhoid patients. Prospective randomized controlled trials are needed to verify our results.

The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients

BACKGROUND

Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear.

OBJECTIVE

This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity.

DESIGN

This was a prospective multicenter uncontrolled study.

SETTINGS

The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022.

PATIENTS

The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry.

MAIN OUTCOME MEASURES

Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score.

RESULTS

One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001).

LIMITATIONS

The study was limited by the small sample size and by the strong selection of the study population.

CONCLUSIONS

Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 .

LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES

ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function

Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients' baseline median Cleveland Clinic Incontinence Score was 15 (10-18); it decreased to 2 (1-4) and 1 (1-2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.

Comparing outcomes of laser hemorrhoidoplasty and LigaSure hemorrhoidectomy in grade II-III hemorrhoidal disease: a retrospective analysis

BACKGROUND

Hemorrhoidal disease is a common ailment that presents a challenge in terms of standard treatment methods. Although surgical hemorrhoidectomy is often considered the gold standard, new surgical techniques have emerged, such as laser hemorrhoidoplasty and LigaSure hemorrhoidectomy, to address postoperative pain, bleeding, and extended return-to-work times. This study aims to compare the outcomes of laser hemorrhoidoplasty and LigaSure hemorrhoidectomy in patients with grade II-III hemorrhoidal disease.

METHODS

A retrospective analysis was conducted on a cohort of patients who underwent laser hemorrhoidoplasty or LigaSure hemorrhoidectomy. Data were collected on postoperative pain, complications, recurrence rates, and return-to-work times. The primary outcome was the difference in postoperative pain between the two groups, as assessed using the Visual Analog Scale (VAS).

RESULTS

Patients in the laser hemorrhoidoplasty group experienced significantly lower postoperative pain compared to those in the LigaSure hemorrhoidectomy group. Bleeding amounts during the operation were also significantly lower in the laser group. However, the recurrence rate was higher in the laser group compared to the LigaSure group (9.4% versus 2.5%). Return to work and normal activities time after laser hemorrhoidoplasty was shorter than after LigaSure hemorrhoidectomy.

CONCLUSION

Laser hemorrhoidoplasty is a minimally invasive technique that can be safely applied in suitable grade II-III patients, offering lower postoperative pain rates, fewer complications, and shorter return to work and normal activity times compared to LigaSure hemorrhoidectomy. However, recurrence rates are still higher for laser hemorrhoidoplasty. Future studies should explore the potential of combining laser hemorrhoidoplasty with other surgical treatments.

Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study

BACKGROUND

Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure.

METHODS

From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152).

CONCLUSIONS

In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.

Rectosigmoid intussusception due to large submucosal lipoma mimicking rectal prolapse

Rectosigmoid intussusception is a rare cause of bowel obstruction, accounting for only approximately 1%-2% of all bowel obstruction cases. While intussusception in adults typically occurs intra-abdominally and presents with signs and symptoms of intestinal obstruction, in rare cases, it can mimic a rectal prolapse if the intussusceptum protrudes through the anal canal. We herein report a case where an octogenarian woman presented with rectosigmoid intussusception through the anal canal, due to a sigmoid colon submucosal lipoma, who eventually required an open Hartmann's procedure. Patients with rectal prolapse symptoms should be carefully examined to rule out intussuscepting masses as a differential, as it would necessitate earlier surgical intervention.

Mid-term efficacy and postoperative wound management of laser hemorrhoidoplasty (LHP) vs conventional excisional hemorrhoidectomy in grade III hemorrhoidal disease: the twisting trend

PURPOSE

Hemorrhoidal disease (HD) is a common condition, and several surgical techniques have been proposed to date without being able to achieve definitive consensus on their use and indications. Laser hemorrhoidoplasty (LHP) is a minimally invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser limiting the postoperative discomfort and pain. The aim of the current study was to evaluate the postoperative outcomes of HD patients undergoing LHP vs conventional Milligan-Morgan hemorrhoidectomy (MM).

METHOD

Postoperative pain, wound care management, symptoms' resolution, patients' quality of life, and length of return to daily activity of grade III symptomatic HD patients undergoing LHP vs MM were retrospectively evaluated. The patients were followed-up for recurrence of prolapsed hemorrhoid or symptoms.

RESULT

From January 2018 to December 2019, 93 patients received conventional Milligan Morgan as control group and 81 patients received laser hemorrhoidoplasty treatment using a 1470-nm diode laser. No significant intraoperative complications occurred in both groups. Laser hemorrhoidoplasty patients experienced lower postoperative pain score (p < 0.0001) and smoother wound management. After 25 ± 8 months follow-up, the recurrence of symptoms occurred in 8.1% after Milligan-Morgan and 21.6% after laser hemorrhoidoplasty (p < 0.05) with a similar Rorvik score (7.8 ± 2.6 in LHP group vs 7.6 ± 1.9 in MM group, p = 0.12).

CONCLUSION

LHP demonstrated high efficacy in selected HD patients guaranteeing lower postoperative pain, easier wound care, higher rate of symptoms resolution, and greater patient appreciation compared to MM, even though it had a higher recurrence rate. Larger comparative studies are needed to address this issue.

EFFECTIVENESS OF PERINEAL PELVIS REHABILITATION COMBINED WITH BIOFEEDBACK AND RADIOFREQUENCY DIATHERMY (RDF) IN ANORECTAL FUNCTIONAL PAIN SYNDROMES ASSOCIATED WITH PARADOXICAL CONTRACTION OF THE LEVATOR ANI MUSCLES. A PROSPECTIVE STUDY

•Anorectal functional pain syndrome is a very often disabling disease with a consequent significant negative impact on the patient's quality of life. Chronic proctalgia, in many patients, is secondary to the paradoxical contraction of the pelvic floor and associated with a dissynergy between the thorax-abdomen and the pelvic floor. •The use of radiofrequency diathermy with a system of static electrodes associated with biofeedback represents a valid rehabilitation option for those patients suffering from anorectal functional pain syndrome because it reduces pain and paradoxical contraction of the levator ani and improves quality of life of the patient. Background - Anorectal functional pain syndrome, also called chronic proctalgia, represents a neglected clinical entity and often confused with other syndromes such as vulvodynia or acute proctalgia. It is a very often disabling disease with a consequent significant negative impact on the patient's quality of life. Chronic proctalgia, in many patients, is secondary to the paradoxical contraction of the pelvic floor and associated with a dissynergy between the thorax-abdomen and the pelvic floor. To improve symptoms in functional anorectal pain syndromes, various rehabilitation techniques are used with the aim of promoting relaxation of the pelvic floor; however, to improve defecatory dynamics in patients with levator ani syndrome, only biofeedback has shown efficacy in a randomized study. The aim of this work is to evaluate whether a rehabilitation protocol with manometric biofeedback and radiofrequency diathermy (mt100 Fremslife emotion Tecar) reduces pain and paradoxical contraction of the levator ani and improves the quality of life in patients with anorectal pain syndromes. functional. Methods - This was a prospective study on 30 patients (20 women and 10 men) with anorectal functional pain syndrome and paradoxical contraction of the pelvic floor enrolled at the UOC of General, Minimally Invasive, Oncological and Obesity Surgery of the AOU "Luigi Vanvitelli" of Naples, Italy, from September 2021 to May 2022. All patients were evaluated with a coloproctological specialist visit followed by anorectal manometry and evaluation of altered clinical physiatric parameters (Brusciano Score). The protocol consisted of 10 rehabilitation sessions of the pelvic floor once a week and lasting approximately 45 minutes. During the sessions the patients were subjected to diathermy / radiofrequency treatment (10 minutes) with a static resistive electrode on the diaphragm, during which they were required to breathe diaphragmatically and to become aware of the perineal muscles, under the supervision of a physiotherapist; followed by application of diathermy with static capacitive (5 minutes) and resistive (10 minutes) electrode at the lumbar level. This was followed by the use of manometric biofeedback (15 minutes of tonic / phasic exercises) in order to instruct the patient on the reflex mechanism to obtain a voluntary relaxation of the external anal sphincter. The variables evaluated were Pain (VAS 0-10) and the questionnaire on the impact of colorectal and anal pathologies on the quality of life (CRAIQ-7) at the beginning, after 3 months and at the end of the treatment. Results - After 10 weeks, the rehabilitation treatment combined with diathermy and manometric biofeedback proved effective in the short term with a reduction in the scores of the Vas scale and CRAIQ-7 questionnaire and an increase in the percentage of release of the anal muscles on anorectal manometry. Conclusion - The use of radiofrequency diathermy with a system of static electrodes associated with biofeedback represents a valid rehabilitation option for those patients suffering from anorectal functional pain syndrome because it reduces pain and paradoxical contraction of the levator ani and improves quality of life of the patient.

Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results

BACKGROUND

Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results.

METHODS

Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated.

RESULTS

Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured.

CONCLUSION

The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

Women with chronic constipation have more bothersome urogenital symptoms

BACKGROUND

The aim of our study was to characterize urogenital symptoms in women with and without constipation, and by severity of constipation.

METHODS

This was a retrospective cohort study conducted at a pelvic floor disorder center in a tertiary healthcare facility from May 2007 through August 2019 and completed an intake questionnaire were included. We collected demographic, physical exam data and quality of life outcomes. The Urinary Distress Inventory (UDI-6) was used to assess urogenital symptoms. Women with constipation completed the Constipation Severity Instrument (CSI). We excluded women with a history of a bowel resection, inflammatory bowel disease, or pelvic organ prolapse symptoms. The cohort was then divided into two groups, constipated and non-constipated, and the prevalence and severity of urogenital-associated symptoms were compared. A secondary analysis was made among constipated subjects stratified by constipation severity based on CSI scores.

RESULTS

During the study period, 875 women (59.5%) had chronic constipation. Women with chronic constipation were more likely to experience urogenital symptoms, such as dyspareunia, urinary hesitancy, and a sensation of incomplete bladder emptying (all p < 0.05). Moreover, on univariate analysis, women with high CSI scores (75 percentile or higher) were found to have higher UDI-6 scores, increased bladder splinting, pad use, urinary frequency and dyspareunia while on multivariate analysis higher UDI score, increased bladder splinting, urinary frequency and dyspareunia were significantly associated (p < 0.05).

CONCLUSION

We found that the presence and severity of chronic constipation worsened the degree of bother from urogenital symptoms. Given that chronic constipation can modulate urogenital symptoms, our study suggests that pelvic floor specialists should assess the presence and severity of urogenital and bowel symptoms to provide comprehensive care.

Therapeutic Efficacy of Ultrasound-Guided High-Voltage Long-Duration Pulsed Radiofrequency for Pudendal Neuralgia

Pudendal neuralgia (PN) is a complex disease with various clinical characteristics, and there is no treatment showing definite effectiveness. This study is aimed at evaluating the clinical efficacy of ultrasound-guided high-voltage long-duration pulsed radiofrequency (PRF) for PN. Two cadavers (one male, one female) were dissected to provide evidence for localization of the pudendal nerve. Patients diagnosed as PN who failed or were intolerant in regular medication were screened for diagnostic local anesthesia block of the pudendal nerve before recruitment. Twenty PN patients were enrolled in this study. In the PRF procedure, the needle tip was inserted medially into the internal pudendal artery under ultrasound guidance. The position of the PRF needle tip was then adjusted by the response of the pudendal nerve to the electrical stimulation within the pudendal area (42°C, a series of 2 Hz, and 20 ms width pulses that lasted for 900 s). Alleviation of pain was assessed by the visual analogue scale (VAS) and sitting time pretreatment and on 7 d, 14 d, 1 m, 2 m, 3 m, and 6 m posttreatment in outpatient follow-up or by telephone interview. Two patients were lost due to intervention-irrelevant reasons. Patients showed significantly decreased VAS scores on 7 d after RFP, compared with pretreatment status (7.0 ± 0.9 vs. 3.2 ± 1.7, P < 0.001). The efficacy remained steady till the end of 6 months, with a final remission rate of 88.9%. Sitting time also significantly lengthened following PRF (7 d, 14 d, 1 m, 2 m, 3 m, and 6 m vs. pretreatment, all P < 0.05). Only short-term ipsilateral involuntary convulsion of the lower extremity was reported in one patient, who recovered within 12 h. Six patients were treated with nonsteroidal drugs for a short time. All patients stopped taking medication finally. In conclusion, the ultrasound-guided high-voltage long-duration PRF approach not only reduced the pelvic pain caused by PN but also improved the quality of life by extending sitting time without nerve injury.

Preservation of superior rectal artery in laparoscopically assisted subtotal colectomy with ileorectal anastomosis for slow transit constipation

BACKGROUND

Slow transit constipation (STC) has traditionally been considered as a functional disorder. However, evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology. If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment, surgical intervention with subtotal colectomy may be effective. The most unwanted complication of the procedure is anastomotic leakage, however, preservation of the superior rectal artery (SRA) may reduce its incidence.

AIM

To evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.

METHODS

This was a single-center retrospective observational study. STC was diagnosed after a series of examinations which included a colonic transit test, anal manometry, a balloon expulsion test, and a barium enema. Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018. The operation time, blood loss, time to first flatus, length of hospital days, and incidence of minor or major complications were recorded.

RESULTS

A total of 32 patients (mean age, 42.6 years) who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA. All patients were diagnosed with STC after a series of examinations. The mean operative time was 151 min and the mean blood loss was 119 mL. The mean day of first time to flatus was 3.0 d, and the mean hospital stay was 10.6 d. There were no any patients conversions to laparotomy. Post-operative minor complications including 1 wound infection and 1 case of ileus. There was no surgical mortality. No anastomosis leakage was noted in any of the patients.

CONCLUSION

Laparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection. Sparing the SRA may protect against anastomosis leakage.

The Appropriateness of Glycerin Enema in Pediatric Patients Visiting the Emergency Department

Objectives: We determined whether glycerin enemas were appropriately prescribed in pediatric fecal impaction patients using the Leech score and identified factors that influenced the prescription of glycerin enemas in the pediatric emergency department (PED). Methods: We included patients who received a glycerin enema at the PED of a tertiary teaching hospital. We divided the study subjects into two groups on the basis of their Leech scores: an appropriate enema group (Leech score ≥ 8), and an inappropriate enema group (Leech score < 8). Logistic regression was performed to determine the factors associated with glycerin enema administration. Results: The data of 998 patients, including 446 patients in the inappropriate enema group (Leech score 5.2 ± 1.7) and 552 patients in the appropriate enema group (Leech score 10.1 ± 1.7), were analyzed. A discharge diagnosis of fecal impaction was observed significantly more frequently (57.1%) in the appropriate enema group, and nonspecific abdominal pain (8.3%) and acute gastroenteritis (40.8%) were diagnosed significantly more frequently in the inappropriate enema group (p < 0.05). Constipation (2.8%) and irritability (3.0%) were slightly more common in the appropriate enema group than in the inappropriate enema group (p < 0.05). According to multiple logistic regression, subjects aged 2–8 years (2–4 years, OR 4.24; 4–8 years, OR 2.83), with vomiting (OR 1.72), with irritability (OR 4.52), and with a prolonged last defecation day (OR 1.2) were most likely to receive appropriate enema administration (p < 0.05). Conclusion: The results showed that in those aged 2–8 years, with vomiting and irritability, and with a prolonged last defecation day, an enema was generally administered appropriately.

Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients

PURPOSE

Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis.

METHODS

Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work.

RESULTS

We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2.

CONCLUSIONS

The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Obstructed defecation syndrome associated with paradoxical puborectalis contraction: osteopathic treatment versus anal biofeedback. Results of a pilot study

BACKGROUND

Biofeedback is the most widespread rehabilitative therapy for the treatment of anismus after failed conservative treatment. Osteopathy represents an alternative therapy for constipation. The aim of this study was to evaluate short- and long-term results of osteopathic treatment as compared to biofeedback in patients with dyssynergic defecation.

METHODS

This was a prospective cohort pilot study on 30 patients with dyssynergic defecation enrolled at the Colorectal Clinic of the University Hospital of Ferrara, Italy, from May 2015 to May 2016 and followed until May 2020. Dyssynergic defecation was defined as the inappropriate contraction of the pelvic floor or less than 20% relaxation of basal resting sphincter pressure (on anal manometry) with adequate propulsive forces during attempted defecation. Dyssynergic patients were divide into 2 treatment groups: 15 patients had osteopathy and 15 patients had biofeedback. Before and 3 months after rehabilitation treatment, all patients had anorectal manometry, defecography, and ultrasound, and were evaluated with the Cleveland Clinic Florida (CCF) constipation score, obstructed defecation syndrome (ODS) score, Colo-rectal-anal Distress Inventory (CRADI-8), Colo-rectal-anal Impact Questionnaire (CRAIQ-7), and the Brusciano Score (BS). To evaluate the efficacy of osteopathy and biofeedback in the long-term, all patients completed the above-mentioned questionnaires 5 years later via a telephone interview.

RESULTS

The two treatments were similarly effective in the short term with reduction in questionnaires scores, and increase in the percentage of anal sphincter release at straining at anorectal manometry in both groups. The ODS score was significantly reduced in biofeedback group (p = 0.021). The 3-month post-treatment BS was lower in the osteopathy group, but this just failed to reach statistical significance (p = 0.050). Periodic rehabilitation reinforcements were provided. The CCF constipation score decreased significantly in the osteopathy group (p = 0.023) after 5 years.

CONCLUSIONS

Osteopathy is a promising treatment for dyssynergic defecation, and it can be associated with biofeedback.

Magnesium Oxide in Constipation

Magnesium oxide has been widely used as a laxative for many years in East Asia, yet its prescription has largely been based on empirical knowledge. In recent years, several new laxatives have been developed, which has led to a resurgence in interest and increased scientific evidence surrounding the use of magnesium oxide, which is convenient to administer, of low cost, and safe. Despite these advantages, emerging clinical evidence indicates that the use of magnesium oxide should take account of the most appropriate dose, the serum concentration, drug-drug interactions, and the potential for side effects, especially in the elderly and in patients with renal impairment. The aim of this review is to evaluate the evidence base for the clinical use of magnesium oxide for treating constipation and provide a pragmatic guide to its advantages and disadvantages.

Enhanced recovery after surgery nursing program, a protective factor for stoma-related complications in patients with low rectal cancer

BACKGROUND

This study aimed to investigate the association between enhanced recovery after surgery (ERAS) nursing program and stoma-related complications (SRCs) and prognosis in patients with low rectal cancer (LRC) undergoing abdominoperineal resection with sigmoidostomy.

METHODS

LRC patients who underwent elective abdominoperineal resection with sigmoidostomy between May 2016 and May 2019 were retrospectively enrolled. The occurrence of early major or minor SRCs (within postoperative 30 days) was set as the primary end-point. Clinicopathological variables and laboratory tests were compared between patients with or without SRCs. The univariate and multivariate logistic regression analyses were performed to investigate risk factors for SRCs. Hospitalization satisfaction-related and prognosis-related variables were compared between LRC patients with or without ERAS nursing program.

RESULTS

A total of 288 patients were enrolled and the incidence of SRCs was 26.7% (77/288). ERAS nursing program was the only independent risk factor for SRCs in LRC patients (OR 2.04, 95%CI 1.31-3.12, P = 0.016) by the multivariate logistic regression analysis. Moreover, ERAS nursing program was associated with higher hospitalization satisfaction rate, faster bowel function recovery, better psychological status, and higher quality of life.

CONCLUSIONS

ERAS nursing program was a protective factor for SRCs and associated with improved prognosis in LRC patients undergoing elective abdominoperineal resection with sigmoidostomy.

Diverting colostomy is an effective procedure for ulcerative chronic radiation proctitis patients after pelvic malignancy radiation

Background

Chronic radiation proctitis (CRP) with rectal ulcer is a common complication after pelvic malignancy radiation, and gradually deteriorating ulcers will result in severe complications such as fistula. The aim of this study was to evaluate effect of colostomy on ulcerative CRP and to identify associated influence factors with effectiveness of colostomy.

Methods

Between November 2011 to February 2019, 811 hospitalized patients were diagnosed with radiation-induced enteritis (RE) in Sun Yat-sen University Sixth Affiliated Hospital, among which 284 patients presented with rectal ulcer, and 61 ulcerative CRP patients were retrospectively collected and analyzed.

Results

The overall effective rate of colostomy on ulcerative CRP was 49.2%, with a highest effective rate of 88.2% within 12 to 24 months after colostomy. 9 (31.1%) CRP patients with ulcers were cured after colostomy and 12 (19.67%) patients restored intestinal continuity, among which including 2 (3.3%) patients ever with rectovaginal fistula. 100% (55/55) patients with rectal bleeding and 91.4% (32/35) patients with anal pain were remarkably alleviated. Additionally, multivariable analysis showed the duration of stoma [OR 1.211, 95% CI (1.060–1.382), P = 0.005] and albumin (ALB) level post-colostomy [OR 1.437, 95% CI (1.102–1.875), P = 0.007] were two independent influence factors for the effectiveness of colostomy on the rectal ulcer of CRP patients.

Conclusions

Colostomy was an effective and safe procedure for treating rectal ulcer of CRP patients, and also a potential strategy for preventing and treating fistula. Duration of stoma for 12–24 months and higher ALB level could significantly improve the effectiveness of colostomy on ulcerative CRP patients.

Comparison of Centella with Flavonoids for Treatment of Symptoms in Hemorrhoidal Disease and After Surgical Intervention: A Randomized Clinical Trial

Phlebotonics’ effects were evaluated to reduce time-to-stop bleeding and anal irritation in 130 patients who complained of hemorrhoidal disease (HD); bleeding and pain after hemorrhoidectomy (31 patients) and hemorrhoidal thrombosis (34 patients) in the short time. Sixty patients were randomized to receive the routine treatment (both conservative and surgical) (control Group C). The treated group (both conservative and surgical) was divided into two subgroups: one treated with flavonoids (Group A, n = 73), the other with Centella (Group B, n = 66). Time-to-stop bleeding was checked at baseline and checkups (0 up to day 42). Healing was estimated with Kaplan-Meier method, the Kruskal-Wallis test estimated changes in the VAS scores. The HD median time-to-stop bleeding was 2 weeks for Groups A and B; 3 weeks for Group C. VAS scores comparison among Groups (irritation): A vs C, p = 0.007; B vs C, p = 0.041; and A vs B, p = 0.782 resulted respectively. As for operated hemorrhoids, the time-to-stop bleeding was 3 and 4 weeks in Groups A and B and 5 in Group C. Histopathology showed an association between flavonoids and piles’ fibrosis (p = 0.008). Phlebotonics in HD, as well as after surgery, showed significant beneficial effects. Flavonoids are the most effective phlebotonics against bleeding and anal irritation.

OUTLET OBSTRUCTED CONSTIPATION AND FECAL INCONTINENCE: IS REHABILITATION TREATMENT THE WAY? MYTH OR REALITY

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

Prognostic significance of the controlling nutritional status (CONUT) score in patients with colorectal cancer: A systematic review and meta-analysis

BACKGROUND

The clinical evidence of the controlling nutritional status (CONUT) score for outcomes has increased in gastroenterological surgical oncology. The aim of this study was to investigate the impact of the CONUT score on outcomes in patients with colorectal cancer (CRC).

METHODS

A literature review was systematically conducted to evaluate the significance of the CONUT score in CRC patients. Meta-analyses of survival were performed to investigate the effects of the CONUT score in CRC patients.

RESULTS

Nine studies met the inclusion criteria, and six studies with 2601 patients were included in the present meta-analyses. High CONUT score was associated with poor overall survival (HR 1.97, 95%CI = 1.40-2.77, P < 0.001), cancer-specific survival (HR 3.64, 95%CI = 1.96-6.75, P < 0.001), and recurrence/relapse-free survival (HR 1.68, 95%CI = 1.23-2.29, P = 0.001) after CRC surgery.

CONCLUSIONS

The CONUT score is a practical prognostic factor associated with prognosis of CRC. Further studies are needed to clarify the significance of the CONUT score in CRC patients.

Elobixibat alleviates chronic constipation in hemodialysis patients: a questionnaire-based study

BACKGROUND

Hemodialysis patients are prone to constipation, which can adversely affect their quality of life (QOL). Elobixibat, a highly selective inhibitor of the ileal bile acid transporter, can increase the bile acid level in the colon and, subsequently, enhance colonic motility and secretion. In hemodialysis patients with chronic constipation, it may have a novel action mechanism. However, the effect of elobixibat on such patients' QOL had not been reported. This study aimed to evaluate the effect of elobixibat on the QOL of hemodialysis patients with chronic constipation.

METHODS

This was a multicenter, observational study that used the Japanese version of the Patient Assessment of Constipation-Quality of Life (PAC-QOL) questionnaire on 27 patients (18 men and nine women, age range 47-90 years), who satisfied the Rome 3 diagnostic criteria for functional constipation and were already taking other drugs for constipation. These patients were administered elobixibat 10 mg/day and were asked to respond to the PAC-QOL questionnaire at baseline and after 4 weeks. Bayesian statistics were used to confirm our results.

RESULTS

The number of spontaneous bowel movements per week increased significantly from 2.6 ± 1.2 to 4.1 ± 2.1 (p < 0.001), and the Bristol Stool Form Scale score significantly improved from 1.9 ± 0.8 to 3.6 ± 0.7 (p < 0.001). The Cronbach's alpha was 0.95, and the Guttman split-half reliability coefficient was 0.90. There were significant decreases in the physical discomfort scores from 1.94 ± 0.79 to 0.97 ± 0.72 (p < 0.001); psychosocial discomfort from 1.16 ± 0.93 to 0.63 ± 0.58 (p < 0.001); worries/ concerns from 1.84 ± 0.73 to 1.27 ± 0.59 (p < 0.001), and satisfaction from 2.79 ± 0.61 to 1.98 ± 0.77 (p < 0.001). The total PAC-QOL score significantly decreased from 1.83 ± 0.79 to 1.17 ± 0.56 (p < 0.001). Bayesian statistics confirmed the results' significance.

CONCLUSIONS

Elobixibat reduced the PAC-QOL scores for hemodialysis patients with chronic constipation and improved the patients' QOL. It may serve as a new option for treating constipation in hemodialysis patients.

Postoperative discomfort and pain in the management of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids

Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II-III degrees hemorrhoids. Consecutive patients with II-III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6 months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24 h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6 months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.

Clinical benefit of oral lactulose for postoperative care of pateints with complicated appendicitis using propensity score matching analysis

Objective

The aim of this study was to investigate the effect of oral lactulose for pediatric patients with complicated appendicitis, who underwent appendectomy.

Background

Oral lactulose was widely used for gastrointestinal function regulation. However, clinical benefit for oral lactulose regarding its effects on recent postoperative gastrointestinal (GI) recovery and long term adhesive small bowel obstruction (ASBO) incidence, especially in the postoperative pediatric population has not yet defined.

Methods

A total of 525 pediatric patients with complicated appendicitis underwent appendectomy were retrospectively reviewed. Among them, 317 cases were subjected to oral lactulose management and 208 patients without, served as control. Propensity score 1:1 matching was carried out to adjust for any potential baseline variables. In 189 paired patients, clinical outcomes, including gastrointestinal recovery variables, incidence of ABSO, as well as adverse events, were compared according to the oral lactulose administration or not.

Results

Patients who received oral lactulose administration achieved early gastrointestinal function recovery, including, first bowel movement (Risk ratio [RR], 1.34; 95% confidence interval [CI] 1.02–2.63, p = 0.005) and first solid feeding (RR, 1.26; 95% CI, 1.01–1.92, p = 0.012). A lower occurrence of ASBO (OR, 0.47; 95% CI, 0.25–0.87; p = 0.011) and lower constipation (Odds ratio [OR], 0.25; 95% CI, 0.13–0.46; p < 0.001), were noted in patients received oral lactulose than in patients without. Furthermore, significantly fewer patients required readmission (OR, 0.56; 95% CI, 0.32–0.99; p = 0.031) and reoperation (OR, 0.29; 95% CI, 0.09–0.92; p = 0.022) in the patients who received oral lactulose administration.

Conclusions

Beneficial effects of oral lactulose administration in pediatric patients undergone appendectomy were indicated, such as accelerating gastrointestinal function recovery, reducing the postoperative incidence of ASBO and constipation, so reduced readmission and reoperation.