Experimental internal anal sphincter replacement with demucosated colonic plication

BACKGROUND

Selective re-creation of a new internal anal sphincter could be indicated when the natural one is irreversibly damaged or excised.

METHODS

In this preliminary experimental work, surgical techniques of internal anal sphincter replacement in pigs were investigated. After preoperative anorectal manometry, surgical procedure was done in two phases: abdominal, mobilization of the colon-rectum to the pelvic floor; and perianal, dissection of the anal canal from the external anal sphincter through the intersphincteric space. The fully mobilized anorectal segment, including the internal anal sphincter, was pulled down through the anus and resected. The distal colonic stump was then demucosated and two types of plications of the demucosated segment were accomplished, each type in three animals. The plicated segment was then returned into the anal canal, inside the external sphincter. Short-term follow-up with clinical and manometric evaluations was performed and, subsequently, histological analysis of the plicated segment, after the animals were sacrificed.

RESULTS

None of the animals became incontinent. Anal manometry identified a high-pressure zone and relaxation reflex in the new anal canal. Histologic studies showed hypertrophy of smooth muscle layers without degenerative changes.

CONCLUSION

This study indicates that a plication of colonic smooth muscle wall can re-create a high-pressure zone in the anal canal after the internal anal sphincter has been excised.

[Endoscopic treatment of intestinal anastomotic leakage in low anterior resection of the rectum by using fibrin adhesive. Our experience]

BACKGROUND

Personal experience about treatment of anastomotic leakage in low anterior resection of the rectum by using human fibrin adhesive "Tissucol" is reported.

METHODS

Eight cases of anastomotic leakage treated with using human fibrin adhesive "Tissucol", are analyzed in a retrospective study. Patients had three/six months-one year follow up. Treatment with human fibrin adhesive "Tissucol" was performed in our Endoscopic ambulatory. Six cases had either an immediate resolution or an ambulatorial follow-up; in 2 cases only, general complications forced to a prolonged hospital stay. The study concerns 58 patients subjected to low anterior resection of the rectum and endoscopic treatment of 8/58 patients with anastomotic leakage. Fistulas were sealed with human fibrin adhesive "Tissucol" by using flexible endoscope. Anastomotic leakage identification leakage was made and low anterior resection of the rectum and sealing with human fibrin adhesive "Tissucol" were performed.

RESULTS

Complete sealing of fistula and rectum patent.

CONCLUSIONS

The excellent results obtained with this non invasive and fast treatment, easily practicable even in ambulatorial regimen, lead the authors to consider it effective and as first-choice treatment of this dangerous complication. The cost/benefit ratio is favorable if compared with the long hospital stay required for other treatments, which also present loaded high morbidity and mortality.

The surgical treatment of pancreatic pseudocysts. Personal experience

BACKGROUND

This study is aimed at contributing to defining a correct therapeutic management of pancreatic pseudocysts (PPCs): indications for treatment, operative timing and technical approach.

METHODS

A retrospective analysis of 28 patients affected by PPC, 22 males (78.5%) and 6 females (21.5%), with a mean age of 52 years (range 17-76) has been performed. The diagnosis was realised by clinical assessment and US (ultrasonography) or CT (computerized tomography) scanning. The treatment consisted in surgical drainage (internal or external) or percutaneous drainage with US guidance: the cystojejunostomy with a Roux-en-Y loop was the first choice technique.

RESULTS

Twenty-two patients (78.5%) under-went a surgical procedure: 19 cystojejunostomies with a Roux-en-Y loop and 3 external drainages. The mean interval between acute pancreatic event and elective surgery was 9 weeks (range 5-21). Perioperative morbidity and mortality was respectively 22.7% (5/22) and 13.6% (3/22). In 4 cases a percutaneous drainage with US-guidance, without morbidity and mortality was performed, but 2 patients required a successive surgical operation for lack of resolution of the PPC. The last 2 patients of this series recovered spontaneously.

CONCLUSIONS

Currently the cystojejunostomy with a Roux-en-Y loop remains the first choice technique for an elective and definitive treatment of PPCs: other techniques (endoscopic internal drainage, surgical or percutaneous external drainage) should be limited to complicated PPCs or to high surgical risk patients. A waiting period of 4-6 weeks following the acute pancreatic event is considered the minimal time necessary before the elective treatment.

[Surgical treatment of pancreatic carcinoma. Our experience]

BACKGROUND

Currently, pancreatic exocrine carcinoma presents high mortality, poor survival after curative surgery and poor resectability rates at the time of diagnosis. The factors which mostly influence prognosis and therapeutic management (curative surgery or palliative treatments) of the patient affected by pancreatic carcinoma, particularly the peroperative stage, are analyzed and discussed in this article.

METHODS

From 1969 to 1997, 142 patients with pancreatic ductal carcinoma were admitted to our Department: at the time of diagnosis only 32 patients (22.5%) were considered resectable, and 30 pancreaticoduodenectomies (PD), 1 distal pancreatectomy (DP) and 1 total pancreatectomy (TP) were performed.

RESULTS

Postoperative morbidity and mortality was 53.1% and 12.5% respectively; the survival at 1, 3 and 5 years was 45.5%, 36.4% and 17.6% respectively. The worst prognosis was seen in N+ and T4 patients, with a mean survival of 9 and 10 months.

CONCLUSIONS

On the basis of these results and of the literature, the indications for curative surgery, the operative strategy and the lymphoadenectomy extension are discussed: these problems are still open and not resolved definitively. The authors conclude by indicating the need for curative surgery for T1/2 N0 M0 tumors: for T3/4 and/or N+ tumors a careful evaluation of single case is necessary, because of high risk/benefit rate. Pancreatic resections (PD, DP) and standard lymphoadenectomy (D1) are performed by the authors, rather than total pancreatectomy and radical lymphadenectomy (D2-3).