Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented

Prospektive Erfassung von Lernkurve und Sicherheit der Stapler-Hämorrhoidektomie [Prospective assessment of the learning curve and safety of stapler hemorrhoidectomy]

INTRODUCTION: Stapled haemorrhoidectomy (SH) is a recently introduced procedure for the surgical excision of haemorrhoids. Actually, there is only limited information concerning the impact of the learning curve, complication rates and long-term results. Therefore, a prospective single-center study was performed with special regard to the learning curve and clinical safety of SH. METHODS: The data of 61 SH performed between March 1999 and May 2001 were analyzed. Operating times, complication rates and outcome results were prospectively recorded and then correlated to the surgical experience of the operating team. Postoperative pain was measured using the visual analogue scale (VAS). Sphincter lesions represented by the patient's incontinence and muscle defects were analyzed by using Williams incontinence score and histological examination of the resected specimen. Clinical follow-up studies were performed three and twelve weeks postoperatively. RESULTS: There were 18 patients with grade II haemorrhoids, 38 patients with grade III haemorrhoids, and five patients with grade IV haemorrhoids. Both, operating times and complication rates decreased with more surgical experience. The mean pain score during the first four postoperative days was 1.9 (range 0-8). Mean hospital stay and mean convalescence time were 1.7 days (range 1-5 days) and 10 days (range 1-31 days), respectively. Incontinence scores revealed only minor differences between pre- and postoperative values. CONCLUSIONS: SH represents a safe and effective new treatment modality for symptomatic haemorrhoids. Meticulous surgical technique and experience are mandatory to achieve excellent clinical results, e.g., reduced postoperative pain, shortened hospital stay and convalescence. We adopted SH to our surgical armamentarium for the treatment of haemorrhoids grade III and recurrent haemorrhoids

Video-assisted sacral nerve stimulation.

BACKGROUND: Sacral nerve simulation (SNS) is an accepted therapy for patients with urinary or bowel dysfunction. However, infection rates are as high as 20% and can result in removal of the expensive device. We present a new video-assisted technique minimizing the risk of infection. METHODS: Between April and July 2005, six consecutive women of median age 68 years (range, 60-74), with faecal incontinence (4 patients) and idiopathic constipation (2 patients) underwent video-assisted electrode implantation for SNS. The motor response of the pelvic floor during percutaneous nerve evaluation and implantation of the permanent lead was monitored by a video optic (same as that normally used for laparoscopic or endoscopic procedures) placed between the legs of the patients. The video optic and the perianal area were completely covered with drapes, separating them from the operating field. RESULTS: All but one screening was successful, and no wound infections at the electrode or at the pocket of the stimulator were noted (mean postoperative follow-up, 8 weeks). CONCLUSIONS: With the use of a video optic, the anus and the implantation site can be completely separated and contamination during the operation becomes unlikely. Furthermore, the response of the pelvic floor to the stimulation is better visualized. We routinely recommend the use of video equipment for SNS electrode implantation

Quality of life and morbidity after permanent sacral nerve stimulation for fecal incontinence.

HYPOTHESIS: Permanent sacral nerve stimulation (SNS) is a promising emerging treatment for fecal incontinence. However, there is little data on morbidity and quality of life (QOL) during long-term stimulation. DESIGN: Prospective trial to assess morbidity and QOL in patients treated with SNS. Median follow-up was 13 months (range, 1-42 months). SETTING: University hospital providing primary, secondary, and tertiary care. PATIENTS: Between December 2001 and July 2005, SNS was tested in 44 patients (30 women), with a median age of 65 years (range, 15-88 years). INTERVENTIONS: Percutaneous nerve evaluation and permanent insertion of an implantable pulse generator. MAIN OUTCOME MEASURES: Morbidity, stool diary, and Wexner Score for fecal incontinence; Hanley Score for urinary incontinence; and Gastrointestinal Quality of Life Index, the 36-item short form health survey, and the Royal London Hospital questionnaire for QOL. RESULTS: A permanent stimulator was implanted in 37 patients (84%). Eight patients (22%) experienced complications that required surgical intervention. (A successful restimulation was possible for 5 of those patients.) Adverse effects of SNS were remedied in 5 patients by reprogramming the stimulator. Wexner Scores decreased from a median of 16 points preoperatively (range, 6-20), to a median of 5 points postoperatively (range, 0-13; P<.001). The median number of involuntary stool losses and for urge defecations also decreased significantly. Significant improvement in QOL was found in both generic and incontinence-specific questionnaires (P<.05). The success rate of SNS was 77% (34 of 44 patients) and 92% (34 of 37) in patients with permanent implantation. CONCLUSIONS: The minimally invasive technique of SNS is safe and effective. Most adverse effects can be easily remedied. Our data demonstrate that SNS significantly improves patients' QOL, including their physical and psychological well-being

Outcome and cost analysis of sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) may be successful in treating incapacitating faecal incontinence. The technique is expensive, and no cost analysis is currently available. The aim of this study was to assess clinical outcome and analyse cost-effectiveness. METHODS: Thirty-six consecutive patients underwent a two-stage SNS procedure. Outcome parameters and real costs were assessed prospectively. RESULTS: SNS was tested successfully in 33 of 36 patients, and 31 patients were stimulated permanently. In the first stage, eight of 36 patients reported minor complications (pain, infection or electrode dislocation), resulting in a cost of euro 4053 (range euro 2838-7273) per patient. For the second stage (permanent stimulation), eight of 33 patients had an infection, pain or loss of effectiveness, resulting in a cost of euro 11,292 (range euro 7406-20,274) per patient. Estimated costs for further follow-up were euro 997 per year. The 5-year cumulative cost for SNS was euro 22,150 per patient, compared with euro 33,996 for colostomy, euro 31,590 for dynamic graciloplasty and euro 3234 for conservative treatment. CONCLUSION: SNS is a highly cost-effective treatment for faecal incontinence. Options for further reduction of SNS costs include strict patient selection, treatment in an outpatient setting and using cheaper devices

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures.

BACKGROUND AND AIMS: Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT). MATERIALS AND METHODS: Between January 2001 and August 2004, 40 patients (21 women), median age 37 years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10 U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6 weeks after the operation. At 1 year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results. RESULTS/FINDINGS: At 6 weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1 year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%. INTERPRETATION/CONCLUSION: Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rate

Sakrale Nervenstimulation in der Behandlung der Stuhlinkontinenz [Sacral nerve stimulation in the treatment of faecal incontinence].

The sacral nerve stimulation is a new promising procedure for faecal incontinence in patients in whom conservative treatments have failed. In contrast to more invasive restorative surgeries (e.g. dynamic graciloplasty or artificial sphincter), sacral nerve stimulation can be tested and performed in outpatient under local anaesthesia. From May 2001 to April 2004, 25 consecutive patients with faecal incontinence underwent percutaneous test-stimulation during 10 to 14 days. The test was positive in 16 of them (64%) in whom a permanent implantation of an internal pulse generator was performed. During the follow up of this group a significant reduction of the number of incontinence episodes and a considerable improvement of quality of life was demonstrated. Complete investigations and restrictive patient selection, as well as a carefully follow up are recommended for the success in sacral nerve stimulation therapy