Położnicze uszkodzenia krocza i aparatu zwieraczowego odbytu. Sposoby leczenia rekonstrukcyjnego

Damage to the perineum, vulva, anal sphincters, rectal wall and the fascial structures of the pelvic floor may be caused by obstetric trauma. Emergency surgical treatment aims at control of the bleeding, anatomical reconstruction of the disrupted tissues and minimization of the risk of infection. Suturing of the rectal wall and mucosa of the anal canal is followed by reconstruction of the perineal body, internal and external anal sphincters, vulva and the perineum. Delayed surgery is undertaken after the complete healing of the obstetric tear. All cicatricial fibers must be saved to reinforce sphincters and perineal body muscles suturing. Anal levators and perineal transvers muscles suturing is used for the rectovaginal septum and pelvic floor reconstruction. Anal sphincters are reconstructed by the ‘overlapping’ technique. X en Z suturing is used for a perineal skin plasty.Uraz porodowy może spowodować uszkodzenie struktur mięśniowych krocza, ściany pochwy, odbytnicy, aparatu zwieraczowego odbytu a także tkanek włóknistych struktur powięziowych narządów dna miednicy. Głównym celem doraźnego zaopatrzenia chirurgicznego jest hemostaza, anatomiczna rekonstrukcja przerwanych tkanek i zminimalizowanie ryzyka zakażenia. W kolejności wykonuje się zszycie błony śluzowej odbytnicy i kanału odbytu, struktur ciała kroczowego, zwieracza wewnętrznego i zewnętrznego odbytu, przedsionka pochwy i skóry krocza. Do odroczonego zabiegu rekonstrukcyjnego przystępuje się po całkowitym zagojeniu rany pourazowej. Włókna tkanki bliznowatej wykorzystuje się jako materiał wzmacniający rekonstrukcję zwieraczy i mięśni ciała kroczowego. Dla rekonstrukcji dna miednicy i przegrody odbytniczo-pochwowej zbliża się do siebie mięśnie dźwigacze odbytu i przemieszcza się mięśnie poprzeczne krocza. Zwieracze odbytu zszywa się techniką „na zakładkę”. Skórna część krocza odtwarza się za pomocą plastyki X en Z

Ocena wyników leczenia wypadania narządów dna miednicy metodą zmodyfikowanej perineokolporektopeksji. Doświadczenia własne

Objectives: Anatomical and functional results of a modified sacral perineocolporectopexy for extreme forms of complex pelvic organs prolapse. Material and methods: Between 2005 and 2010, 10 women aged 47-75 years were treated by abdomino-perineal implantation of polypropylene mesh for modified sacral perineocolporectopexy and subsequently followed-up. They were suffering from enterocele (9 pts), genital prolapse (8 pts), descending perineum (5 pts), rectal prolapse (4 pts), rectocele (3 pts). Five women were incontinent (mean Wexner: 9) and six had incomplete rectal evacuation. Defecography revealed enterocele III°(5 pts) and II°(4 pts). MR designed descending perineum in 5 pts (mean: 3,8cm). Results: Permanent reconstruction of the pelvic floor and remission of organs prolapse was achieved at 12-months follow-up in all except 1 patient. There were 2 small vaginal erosions of the mesh and 1 haematoma within the pelvic floor. Improvement at rectal emptying was found in 4 patients, feeling of pelvic heaviness in 6 patients, dyspareunia in 3 patients. Mean incontinence score decreased from 9 to 4. Conclusions: 1. Modified sacral perineocolporectopexy is effective in the treatment of complex pelvic floor anatomical defects and organ prolapse. 2. Improvements in rectal emptying, pelvic feeling of heaviness and dyspareunia have been achieved. 3. The implant tolerance was good and the complications rate was law.Cel pracy: Ocena wyników leczenia wypadania narządów dna miednicy metodą zmodyfikowanej perineokolporektopeksji. Materiał i metody: W latach 2005–2010, 10 pacjentek w wieku od 45 do 75 lat zostało poddanych zabiegowi perineokolporektopeksji z implantacją siatki polipropylenowej z dostępu brzuszno-kroczowego. U 9 pacjentek występowało enterocele, u 8 wypadanie narządów rodnych, w 5 przypadkach obniżenie dna miednicy, w 4 przypadkach wypadanie odbytnicy, a w 3 rektocele. Pięć kobiet skarżyło się na nietrzymanie stolca (śr Wexner: 9) a 6 na brak pełnego opróżnienia odbytnicy. Defekografia wykazała obecność enterocele III° u 5 pacjentek i II° u kolejnych 4 rezonans magnetyczny uwidocznił obniżenie dna miednicy w 5 przypadkach (śr o 3,8cm). Wyniki: U 9 pacjentek w 12-mięsięcznej obserwacji osiągnięto trwałą rekonstrukcję dna miednicy i ustąpienie wypadania narządów. Odnotowano dwa przypadki erozji siatki przez pochwę oraz jeden krwiak w miednicy mniejszej. Poprawę opróżniania odbytnicy stwierdzono u 4 pacjentek, uczucia ciężkości w miednicy u 6, a dyspareunii u 3 kobiet. Średni współczynnik nietrzymania stolca obniżył się z 9 do 4. Wnioski: 1. Zmodyfikowana krzyżowa perineokolporektopeksja jest skutecznym leczeniem złożonych anatomicznie defektów dna miednicy oraz wypadania narządów. 2. Osiągnięto poprawę w zakresie opróżniania odbytnicy, uczucia ciężkości w miednicy i dyspareunii. 3. Zabieg cechował się dobrą tolerancją materiału protetycznego i niskim odsetkiem powikłań

Prosthetic materials for treating posterior vaginal wall prolapse and rectocele — own experience

Objectives: This report describes results of posterior vaginal wall prolapse and rectocele treatment performing tension free reconstruction method with polypropylene mesh implantation.Material and methods: In years 2001 to 20015, 71 female patients in age of 42–82 years were surgically treated. Besides difficult emptying they complained of feeling of heaviness in the pelvis (38%) and dyspareunia (16.9%). Defecography and magnetic resonance proved the presence of rectocele in 84.5%, enterocele in 38%, descending perineum in 28.2%, genital organ prolapse in 23.9%, and rectal prolapse in 22.5% cases. 37 patients with defects of low location have undergone implantation of prosthetic material from vaginal approach. In cases of high location and genital organ prolapse abdominal approach was done.Results: Permanent reconstruction of the rectovaginal septum has been achieved in 70 patients (98%). Symptoms of dyschesia, pelvic plain, heavy straining were persisted in 4 patients (10.3%). 3 cases of mash erosions were diagnosed. One patient was reoperated. Among 6 other patients who needed futher surgical treatment only one was reoperated because of vaginal prolapse. 81.7% of patients was satisfied with their treatment.Conclusion: Using prosthetic materials in pelvic floor defects treatment is characterized by high efficacy and low complication percentage

Practical approach to constipation in adults

The authors present epidemiology, etiology, pathophysiology, management, and treatment of constipation including proper qualification for surgery. Constipations can be divided into more common – primary and less frequent – secondary. The latter may occur due to organic lesions of the large bowel, in the course of metabolic and endocrine disorders, or neurological and psychiatric diseases. Constipation may also be a side effect of multiple medications. In turn, primary constipation is either a slower movement of contents within the large bowel or, twice as likely, pelvic floor dysfunction with the inability to adequately evacuate the contents from the rectum. Symptoms such as infrequent defecation and decreased urge to defecate indicate rather colonic inertia whereas prolong straining even in case of loose stools, and feeling of incomplete evacuation are typical of obstructed defecation. Digital rectal examination reveals common anorectal defects presenting with constipation such as tumors, anal fissures and strictures, and rectocele, or less frequent changes such as rectal intussusception and enterocele. Proctologic examination should include the assessment of the anal sphincter tone and the pelvic floor movement. Barium enema or colonoscopy are necessary to confirm or exclude colorectal organic lesions, mostly in patients with alarm features. More accurate differentiation between slow transit constipation and obstructed defecation is possible with tests such as colonic transit time, defecography and anorectal manometry. Treatment of constipation, irrespective of the cause, is initiated with lifestyle modification which includes exercise, increased water intake and a high-fiber diet. Pharmacologic treatment is started with osmotic agents followed by stimulant laxatives. In turn, biofeedback therapy is a method of choice for the treatment of defecation disorders. There is a small group of patients with intractable slow-transit constipation and descending perineum syndrome who require surgery. Surgical treatment is also indicated in patients with symptomatic rectocele, and advanced rectal intussusception. Enterocele can be corrected during perineopexy performed for the descending perineum

Trace elements and rat pouchitis

The procedure of restorative proctocolectomy is associated with a complete removal of the colon and slight reduction of ileum length, which together can lead to systemic shortages of trace elements. Inflammatory changes in the pouch mucosa may also have some impact. However, there is no data on trace elements in pouchitis. Therefore, in the present study we aimed to assess the effect of acute pouchitis on the status of selected trace elements in rats. Restorative proctocolectomy with the construction of intestinal J-pouch was performed in twenty-four Wistar rats. Three weeks after the surgery, pouchitis was induced. Eight untreated rats created the control group. Liver concentrations of selected micronutrients (Zn, Cu, Co, Mn, Se) were measured in both groups six weeks later, using inductively coupled plasma mass spectrometry. Liver concentrations of trace elements did not differ between the study and the control groups. However, copper, cobalt and selenium concentrations [μg/g] were statistically lower (p<0.02, p<0.05 and p<0.04, respectively) in rats with severe pouchitis (n=9) as compared with rats with mild pouchitis (n=7) [median (range): Cu - 7.05 (3.02-14.57) vs 10.47 (5.16-14.97); Co - 0.55 (0.37-0.96) vs 0.61 (0.52-0.86); Se - 1.17 (0.69-1.54) vs 1.18 (0.29-1.91)]. In conclusion, it seems that acute pouchitis can lead to a significant deficiency of trace elements

Use of Negative Pressure Wound Therapy after Endovascular Revascularization in a Patient with Diabetic Foot Syndrome Complicated by Sepsis

Pacjent lat 60, przyjęty do szpitala z powodu ostrego niedokrwienia kończyny dolnej prawej z martwiczymi zmianami po stronie grzbietowej i zewnętrznej stopy. Zmiany martwicze o szybko postępującym charakterze - owrzodzenia III/IV stopień według klasyfikacji Wagnera. Pacjent choruje na cukrzycę typu drugiego oraz na nadciśnienie tętnicze. Chory pali papierosy w ilości 1,5 paczki dziennie od 40 lat, prowadzi siedzący tryb życia. Leczenie zachowawcze polegało na miejscowym zastosowaniu maści z antybiotykiem o szerokim spektrum działania. Chorego poddano operacji rewaskularyzacyjnej i leczeniu opatrunkiem podciśnieniowym. Niewłaściwa pielęgnacja opatrunku V.A.C. i niekorzystne warunki zewnętrzne w oddziale chirurgicznym przyczyniły się prawdopodobnie do rozwoju zakażenia miejscowego i posocznicy co w konsekwencji było przyczyną amputacji kończyny

La literatura vasca contemporánea: ¿una literatura minoritaria y periférica?

El presente articulo es un intento de encontrar respuesta a la pregunta sobre el caracter periferico y minoritario de la literatura escrita en la lengua vasca, basandose en las propuestas teoricas desarrolladas por Itamar Even-Zohar en el marco de su teoria de los polisistemas, en las indagaciones realizadas acerca de las literaturas menores por Gilles Deleuze y Felix Guattari y tambien en las reflexiones sobre los sistemas literarios perifericos, hechas por Jon Kortazar. Despues de presentar brevemente la historia de la literatura vasca y las circunstancias politico-sociales que determinaron su desarrollo, se llega a la situacion actual en la que se encuentra dentro del sistema literario europeo y las perspectivas de futuro que se abren ante la ultima generacion de los creadores vascos. En el presente trabajo se muestra tambien la historia de la lengua vasca, el euskera, y las condiciones historicas de su desarrollo, dada la importancia que tuvo en el proceso de la formacion de la literatura eusquerica

Pancreaticopleural Fistula as a Rare Cause of Both-Sided Pleural Effusion

A pancreaticopleural fistula is a rare cause of pleural effusion. It is a complication of chronic or acute pancreatitis. It is rarely formed to the right or both pleural cavities. Diagnosis and proper treatment often turn out to be difficult and require the cooperation of a multidisciplinary team. The authors present the case of a 59-year-old patient treated for recurrent pleural effusion of unknown origin, first to the left and then to the right pleural cavity. After many months of treatment, the diagnosis of a pancreaticopleural fistula was made. The patient underwent surgery, which finally led to a successful complete recovery. Pancreaticopleural fistula should always be considered in patients with pleural effusion of unknown origin

Advantages of implantation of acellular porcine-derived mesh in the treatment of human rectocele – Case report

Introduction A rectocele is a hernation of the rectum into the vaginal lumen developing as a consequence of weakness of the rectovaginal septum. It affects about 18% of women after childbearing age. Symptoms associated with a rectocele include constipation, vaginal fullness or heaviness, feeling of a bulging mass within vagina, incomplete stool evacuation and dyspareunia. Current methods of surgical treatment of a rectocele often require implantation of a mesh graft. In most of cases, synthetic and non-absorbable meshes are used. Although implantation of a synthetic and non-absorbable mesh is effective in the treatment of rectocele, a high rate of mesh erosion has been reported. Case report This study presents a surgical technique and case report for the treatment of a rectocele in a 46-year-old women by implantation of a porcine-derived absorbable collagen mesh (Pelvicol®) by transvaginal approach, with six year follow-up. A review of the literature concerning implantation of Pelvicol® for the treatment of rectocele was also undertaken. Conclusions The clinical experience and review of the literature by the authors suggest that a porcine-derived acellular mesh is non-cytotoxic, pyrogenic or allergenic, and the application of a biomesh in the management of rectocele is effective and safe, and the risk of mesh erosion is very low