Video-assisted anal fistula treatment : pros and cons of this minimally invasive method for treatment of perianal fistulas

Purpose. The purpose of this paper is to present results of a single-center, nonrandomized, prospective study of the video-assisted anal fistula treatment (VAAFT). Methods. 68 consecutive patients with perianal fistulas were operated on using the VAAFT technique. 30 of the patients had simple fistulas, and 38 had complex fistulas. The mean follow-up time was 31 months. Results. The overall healing rate was 54.41% (37 of the 68 patients healed with no recurrence during the follow-up period). The results varied depending on the type of fistula. The success rate for the group with simple fistulas was 73.3%, whereas it was only 39.47% for the group with complex fistulas. Female patients achieved higher healing rates for both simple (81.82% versus 68.42%) and complex fistulas (77.78% versus 27.59%). There were no major complications. Conclusions. The results of VAAFT vary greatly depending on the type of fistula. The procedure has some drawbacks due to the rigid construction of the fistuloscope and the diameter of the shaft. The electrocautery of the fistula tract from the inside can be insufficient to close wide tracts. However, low risk of complications permits repetition of the treatment until success is achieved. Careful selection of patients is advised

Upper extremity surface electromyography signal changes after laparoscopic training

Introduction: Objective measures of laparoscopic skill in training are lacking. Aim: To evaluate the changes in the surface electromyography (sEMG) signal during laparoscopic training, and to link them to intracorporeal knot tying. Material and methods: Ten right-handed medical students (6 female), aged 25 ±0.98, without training in laparoscopy, were enrolled in the study. With no additional training, they tied intracorporeal single knots for 15 min. Then underwent laparoscopic training and redid the knot tying exercise. During both events, sEMG was recorded from 8 measurement points on the upper extremities and neck bilaterally. We analyzed changes in sEMG resulting from training and tried to find sEMG predictive parameters for higher technical competence defined by the number of knots tied after the training. Results: The average number of knots increased after the training. Significant decreases in activity after the training were visible for the non-dominant hand deltoid and trapezius muscles. Dominant and non-dominant hands had different activation patterns. Differences largely disappeared after the training. All muscles, except for the dominant forearm and non-dominant thenar, produced a negative correlation between their activities and the number of tied knots. The strongest anticorrelation occurred for the non-dominant deltoid (r = –0.863, p < 0.05). Relatively strong relationships were identified in the case of the non-dominant trapezius and forearm muscles (r = –0.587, r = –0.504). Conclusions: At least for some muscle groups there is a change in activation patterns after laparoscopic training. Proximal muscle groups tend to become more relaxed and the distal ones become more active. Changes in the non-dominant hand are more pronounced than in the dominant hand

Why do Polish medical students resign from pursuing surgical careers? A survey study

Background: In recent years, the interest of Polish medical students in choosing a career in surgical subspecialties has been declining. In the face of a growing demand for surgical procedures it seems essential to find the reasons responsible for that situation. Aim: The aim of the study was to evaluate the level of interest in pursuing surgical careers among Polish medical students and to identify factors that may influence their decision. Material and methods: An anonymous questionnaire was distributed electronically among students from 11 different Polish medical universities. Results: We surveyed 595 individuals (190 male and 405 female). 48% of them declared interest in choosing surgical subspecialty as a career. The percentage of students who considered it before medical school was higher and reached almost 65%. Slight or no interest in surgery as a field of study (OR = 20.6), self-assessment of surgical predispositions as unsatisfactory (OR = 14.3), feeling unable to enter and accomplish surgical specialty (OR = 5.2), being discouraged by the partner (OR = 3.4), negative past experience with the surgical environment (OR = 3.2), not having a surgeon as a mentor (OR = 2.6), no authorship of journal articles or congress presentations (OR = 1.9) and first contact with the operating theatre >2nd year of study (OR = 1.9) were found to be the independent risk factors of abandoning a surgical career. Conclusions: Most medical students are interested in pursuing a surgical specialty at some time during their education. However, being discouraged by lifestyle issues, surgical training quality or experiencing gender discrimination, they often resign from such a career path

Intraoperative neuromonitoring of hypogastric plexus branches during surgery for rectal cancer - preliminary report

Cel: Celem pracy jest przedstawienie własnych, wstępnych doświadczeń z zastosowaniem techniki śródoperacyjnego neuromonitoringu w trakcie wycięcia odbytnicy. Materiał i metody: Do zabiegu ze śródoperacyjnym neuromonitoringiem zakwalifikowano 4 pacjentów z rakiem odbytnicy (2 kobiety, 2 mężczyzn) w wieku od 42 do 53 lat. U wszystkich chorych przed zabiegiem przeprowadzono badania czynnościowe okolicy anorektalnej. Potencjały czynnościowe kompleksu zwieraczy wywołane stymulacją włókien nerwowych odczytywano z pomocą implantowanych przed zabiegiem elektrod. Ponadto do pęcherza moczowego zakładano standardowy cewnik Foleya nr 18, do którego podłączano trójnik rozdzielający odpływ moczu i przewód z podłączonym przekaźnikiem ciśnieniowym odczytującym zmiany ciśnienia w pęcherzu moczowym wskutek skurczów wypieracza pęcherza w trakcie stymulacji. Wyniki: Przygotowanie do neuromonitoringu wydłużyło czas zabiegu o 30–40 minut, a w przypadku dwóch pierwszych zabiegów o 60–80 minut. Faza neuromonitoringu w trakcie zabiegu zabiera dodatkowo 20 do 30 minut. U wszystkich chorych w trakcie preparowania przeprowadzono stymulacje gałęzi splotu podbrzusznego dolnego w ich anatomicznym położeniu. U trzech chorych uzyskano odpowiedź zarówno z pęcherza, jak i zwieracza we wszystkich płaszczyznach stymulacji. U jednego chorego stwierdzono brak odpowiedzi z pęcherza po stronie lewej. U tego chorego po zabiegu wystąpiły objawy pęcherza neurogennego. Wnioski: Bazując na dostępnej literaturze oraz naszych pierwszych doświadczeniach, stwierdzamy, że monitorowanie ciśnienia w pęcherzu moczowym oraz zapis sygnału elektromiograficznego ze zwieraczy umożliwia wizualizację i zaoszczędzenie struktur nerwowych układu autonomicznego, zarówno w części sympatycznej, jak i parasympatycznej. Sygnał uzyskany śródoperacyjnie wydaje się wykazywać korelacje z obrazem klinicznym i badaniami czynnościowymi po zabiegu. Celem obiektywizacji wyników niezbędne są badania czynnościowe przed i po zabiegu oraz ocena na większej liczbie chorych.Aim: The aim of this study was to present our preliminary experience with intraoperative neuromonitoring during rectal resection. Materials and methods: We qualified 4 patients (2 women, 2 men; age 42 – 53 years) with rectal cancer for surgery with intraoperative neuromonitoring. In all patients, functional tests of the anorectal area were performed before surgery. Action potentials from the sphincter complex in response to nerve fiber stimulation were recorded with electrodes implanted before surgery. Moreover, we inserted a standard, 18FR Foley’s urinary catheter to which a T-tube was connected to allow urine outflow and measurement of pressure changes in the bladder induced by detrusor contractions during stimulation. Results: Setting up neuromonitoring prolonged surgery time by 30 to 40 minutes, or even by 60 to 80 minutes in the case of the first two patients. Neuromonitoring itself took additional 20 to 30 minutes during surgery. In all patients, we stimulated branches of the inferior hypogastric plexus in their anatomical position during dissection. In three patients, we evoked responses both from the bladder and the sphincter in all planes of stimulation. In one patient, there was no response from the left side of the bladder, and in the same patient, we observed symptoms of neurogenic bladder. Conclusions: Based on the available literature and our own experience, we state that monitoring of bladder pressure and electromyographic signals from rectal sphincters enables visualization and preservation of autonomic nervous system structures, both sympathetic and parasympathetic. Intraoperative signals seem to be correlated with clinical presentation and functional examinations after surgery. In order to objectify our results, it is necessary to perform functional examinations before and after surgery in a larger group of patients

Implantation of autologous muscle-derived stem cells in treatment of fecal incontinence : results of an experimental pilot study

Background The aim of this study is to present results of the implantation of autologous myoblasts into the external anal sphincter (EAS) in ten patients with fecal incontinence. Methods After anatomical and functional assessment of the patients’ EAS, a vastus lateralis muscle open biopsy was performed. Stem cells were extracted from the biopsy specimens and cultured in vitro. Cell suspensions were then administered to the EAS. Patients were scheduled for follow-up visits in 6-week intervals. Total follow-up was 12 months. Results All biopsy and cell implantation procedures were performed without complications. Nine of the patients completed a full 12-month follow-up. There was subjective improvement in six patients (66.7 %). In manometric examinations 18 weeks after implantation, squeeze anal pressures and high-pressure zone length increased in all patients, with particularly significant sphincter function recovery in five patients (55.6 %). Electromyographic (EMG) examination showed an increase in signal amplitude in all patients, detecting elevated numbers of propagating action potentials. Twelve months after implantation two patients experienced deterioration of continence, which was also reflected in the deterioration of manometric and EMG parameters. The remaining four patients (44.4 %) still described their continence as better than before implantation and retained satisfactory functional examination parameters. Conclusions Implantation of autologous myoblasts gives good short-term results not only in a subjective assessment, but also in objective functional tests. It seems that this promising technology can improve the quality of life of patients with fecal incontinence, but further study is required to achieve better and more persistent results