Botulinum toxin for spastic GI disorders [2]

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The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: A systematic review and meta-analysis

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Treating chronic anal fissure with botulinum neurotoxin

Recent reports confirm that the management of chronic anal fissure has undergone extensive re-evaluation during the past few years. This rejuvenation of interest is attributable to the application of neurochemical treatment, which has contributed to the tendency to treat the disease on an outpatient basis. The use of botulinum neurotoxin seems to be a promising and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence. Indeed, botulinum neurotoxin has been successfully used selectively to weaken the internal anal sphincter as a treatment for chronic anal fissure. It is also more efficacious than nitrate therapy, and is not related to the patient's willingness to complete treatment

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2–3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non‐operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum‐assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy

Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a non-randomized controlled trial

BACKGROUND: Although lateral internal sphincterotomy is the gold-standard treatment for chronic anal fissure, intrasphincteric injection of botulinum toxin seems to be a reliable new option. The aim of this non-randomized study is to compare the effect of lateral internal sphincterotomy and botulinum toxin injection treatments on the outcome and reduction of anal sphincter pressures in patients with chronic anal fissure. METHODS: Patients with chronic anal fissure were treated with either botulinum toxin injection or lateral internal sphincterotomy by their own choice. Maximal resting pressure and maximal squeeze pressure measurements were performed before and 2 weeks after treatments by anal manometry. Patients were followed for fissure relapse during 14 months. RESULTS: Twenty-one consecutive outpatients with posterior chronic anal fissure were enrolled. Eleven patients underwent surgery and ten patients received botulinum toxin injection treatment. Before the treatment, anal pressures were found to be similar in both groups. After the treatment, the maximal resting pressures were reduced from 104 ± 22 mmHg to 86 ± 15 mmHg in the surgery group (p < 0.05) and from 101 ± 23 mmHg to 83 ± 24 mmHg in the botulinum toxin group (p < 0.05). The mean maximal squeeze pressures were reduced from 70 ± 27 mmHg to 61 ± 32 mmHg (p > 0.05) in the surgery group, and from 117 ± 62 mmHg to 76 ± 34 (p < 0.01) in the botulinum toxin group. The fissures were healed in 70 percent of patients in the botulinum group and 82 percent in the surgery group (p > 0.05). There were no relapses during the 14 months of follow up. CONCLUSION: Lateral internal sphincterotomy and botulinum toxin injection treatments both seem to be equally effective in the treatment of chronic anal fissure

An invited commentary on: “A randomized controlled trial on irrigation of open appendectomy wound with gentamicin-saline solution versus saline solution for prevention of surgical site infection.” (Int J Surg 2020; 81:140–146)

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An Invited Commentary on “comparison of the safety and efficacy of single-stage endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy versus two-stage ERCP followed by laparoscopic cholecystectomy six-to eight weeks later: A randomized controlled trial” (Int J Surg 2020;76:37–44)

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Whitehead's hemorrhoidectomy. A useful surgical procedure in selected cases

At the present time Milligan-Morgan's operation is the most diffusely employed and is widely considered to be the most effective of the various surgical techniques for the treatment of hemorrhoids. In this study we report our experience with Whitehead's radical hemorrhoidectomy. In a 5-year period, 1450 patients with hemorrhoids were treated at our coloproctologic unit. We routinely carry out the Milligan-Morgan operation. Nevertheless, in 26 patients the Milligan-Morgan operation was judged to be impossible to perform, in that the prolapsed hemorrhoids were completely irreducible and it was not possible to distinguish and separate the three piles. These patients thus underwent Whitehead's radical hemorroidectomy. All the patients who underwent Whitehead's operation were discharged within the fifth post-operative day. No episodes of incontinence were observed in any patient. The patients were followed for three years after the operation. In only one case did we verify an anal substenosis three months after the operation, which resolved after the use of anal dilators for one month. The stenosis did not recur in the course of follow-up. There were no cases of mucosal ectropion. In conclusion, the type of hemorrhoidectomy which a surgeon performs is primarily based on the surgeon's experience and training. Nevertheless, a competently performed Whitehead's hemorrhoidectomy can give satisfying results. These results are explained by improved knowledge of the anatomy of the anal region and a more accurate surgical technique. On the basis of our experience we believe that Whitehead's hemorrhoidectomy still has its place in selected cases with precise indications

A Commentary on “Incidence and risk factors for postoperative pancreatic fistula in 2089 patients treated by radical gastrectomy: A prospective multicenter cohort study in China” (Int J Surg 2022;98:106219)

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Treatment of puborectalis syndrome with progressive anal dilation

PURPOSE: The aim of this study is to assess the ability of progressive anal dilations to improve frequency of spontaneous bowel movements in patients with puborectalis syndrome (PRS). METHOD: Thirteen patients (9 females and 4 males; mean age, 37 years) with severe, chronic constipation caused by PRS were treated with daily, progressive anal dilation for a three- month period. Three dilators of 20, 23, and 27 mm in diameter were used. Dilators were inserted every day for 30 minutes (10 minutes each dilator). Patients were evaluated with anorectal manometry and defecography halfway through treatment, at the end of treatment, and six months after the end of treatment. At six months, patients also underwent physical examination. RESULTS: There was a significant improvement of weekly mean spontaneous bowel movements from zero to six (P &lt; 0.0001), and the need for laxatives decreased from 12 patients with a weekly mean of 4.6 to 2 patients once per week (P &lt; 0.001). Enemas used before treatment by eight patients who had a weekly mean of 2.3 were, after treatment, needed only by three patients once per week (P &lt; 0.01). During straining, tone measured with anorectal manometry decreased from 93 to 62 mmHg after six months of the end of therapy (F = 6.97; P &lt; 0.01), and anorectal angle measured with defecography during the strain increased from 95°to 110°(P = not significant). CONCLUSIONS: Daily progressive anal dilation should be considered as the first and most simple therapeutic approach in patients with PRS