Transanal open hemorrhoidopexy

INTRODUCTION: Despite all developments in the recent years, the choice of an adequate treatment for hemorrhoids remains a problem. The hemorrhoidopexy as described by Longo and the Doppler-guided hemorrhoidal artery ligation follow a concept different from the excision and destruction techniques from earlier years. In both techniques, the hemorrhoidal tissue is preserved, as it may be important for anal sensation and continence. The high costs of the circular stapler gun and the Doppler methods can probably be overcome by the proposed technique, a transanal open hemorrhoidopexy, while simultaneously preserving hemorrhoidal tissues. METHODS: Between November 2006 and May 2007, 38 patients with third-degree hemorrhoids were treated with open transanal hemorrhoidopexy. All patients were positioned in the lithotomy position and operated under general anesthesia; the anal mucosa was stitched to the rectal wall with four Z-stitches after removal of a small rectal mucosa flap about 4 cm from the dentate line. The four stitches were circumferentially positioned at equal distances. Postoperatively, the patients followed a fiber-rich diet for one week. RESULTS: Most patients (n = 32, 84 percent) were without any complaint upon follow-up at one week. Six patients (16 percent) experienced pain and were treated with oral analgesics. One patient (3 percent) experienced minor bleeding that stopped spontaneously. After one month follow-up, 34 patients (89 percent) had no symptom complaints. Two patients (5 percent) experienced segmental prolapse and two patients (5 percent) had remaining pruritus. No patient needed another intervention. CONCLUSION: The proposed operation, transanal open hemorrhoidopexy, appears to be an effective technique. The procedure can be performed under direct vision and is very cost effective compared to the other hemorrhoidal tissue-sparing procedures

Zelf retrograad spoelen: behandeling van fecale incontinentie na lage anterieure resectie

Two patients, a woman aged 75 and a man aged 63 years, developed faecal incontinence after low anterior resection. Their external sphincter function was intact. They were advised to irrigate their bowel with normal tap water and reached complete pseudocontinence. Faecal incontinence is not always due to sphincter dysfunction. One of the other causes of incontinence is the lack of compliance of the rectum, as seen in patients with a low anterior resection. The part of the colon that has replaced the original rectum is not able to distend in the same manner as the rectum. Irrigation of the colon is a simple means of allowing the patient to achieve pseudocontinence. When the colon is cleaned it will take one or two days before new faeces arrive and a risk for incontinence occurs. It is important to irrigate with safe tap water at a temperature of around 37 degrees C. Most patients treated in this way feel safe to go out again. The irrigation can be performed in patients without the need for extensive diagnostics. This method of irrigation can be used in other forms of faecal incontinence as well

Neuromodulation for functional bowel disorders

In patients with functional bowel disorders not responding to maximal medical treatment, bowel lavage or biofeedback therapy, can nowadays be treated by sacral nerve neuromodulation (SNM). SNM therapy has evolved as a treatment for faecal incontinence and constipation. The exact working mechanism remains unknown. It is known that SNM therapy causes direct stimulation of the anal sphincter and causes changes in rectal sensation and several central nervous system areas. The advantage of SNM therapy is the ability to do a minimally invasive temporary screening phase to assess permanent stimulation outcome. Ideal candidates for SNM therapy are not known. Several studies have described positive and negative predictive factors, but the temporary screening remains the instrument of choice. Clinical results are good and as the technique is developing, fewer complications occur. New indications for SNM include constipation and anorectal or pelvic pain

Effect of sacral neuromodulation on the rectum

BACKGROUND: Sacral neuromodulation (SNM) is a new treatment for faecal incontinence. At present the exact underlying mechanism is still unclear. Modulation of the sacral reflex arcs might have an effect on rectal sensitivity, wall tension and compliance. METHODS: Fifteen consecutive patients with faecal incontinence who qualified for SNM underwent barostat measurements before and during neuromodulation. An 'infinitely' compliant plastic bag with a volume of 600 ml was placed in the rectum and connected to a computer-controlled barostat system. An isobaric phasic distension protocol was used. Patients were asked to report rectal filling sensations: first sensation (FS), earliest urge to defaecate (EUD) and an irresistible, painful urge to defaecate (maximum tolerated volume; MTV). Rectal wall tension and compliance were calculated. RESULTS: During isobaric phasic distension each patient experienced all rectal filling sensations at the time of stimulation. Median volume thresholds decreased significantly during stimulation, from 98.1 to 44.2 ml for FS (P = 0.003), from 132.3 to 82.8 ml for EUD (P = 0.001) and from 205.8 to 162.8 ml for MTV (P = 0.002). Pressure thresholds tended to be lower for all filling sensations, but only that to evoke MTV was reduced significantly by stimulation (37.3 versus 30.3 mmHg; P = 0.005). Median rectal wall tension for all filling sensations decreased significantly with stimulation. There was no significant difference between compliance before and during stimulation. CONCLUSION: SNM affects rectal sensory perception, but further research is required to clarify the mechanism