Delorme’s Procedure for Rectal Prolapse

PURPOSE: Clinical and physiological results of Delormes procedure were assessed retrospectively in patients undergoing this procedure for rectal prolapse. METHODS: A consecutive series of 31 patients (7 males, 24 females; age, 14–93, mean 70 years) with full-thickness, rectal prolapse were treated by Delormes procedure between 1994 and 2002. Median follow-up was 39 (range, 6–96) months. RESULTS: Good results were achieved in 27 patients (87 percent), prolapse recurrence was observed in 4 (13 percent), and mean recurrence time was 14 (range, 3–25) months. There were no postoperative deaths. Minor complications occurred in four patients. The median changes in preoperative and postoperative physiologic patterns in 16 patients were as follows: resting pressure from 21.0 (range, 5–48) to 23.5 (range, 12–76) cm H2O (P = 0.030), squeeze pressure from 64.0 (range, 27–248) to 108.0 (range, 32–264) cm H2O (P = 0.041), volume at first sensation from 100 (range, 70–180) to 70 (range, 40–130) ml (P = 0.002), maximum tolerated volume from 260 (range, 120–400) to 160 (range, 70–400) ml (P = 0.001). Incontinence improved in 63 percent. No patient became constipated, and 38 percent of those constipated preoperatively improved. The preoperative incontinence score improved from 11.5 (range, 1–20) to 6.0 (range, 0–20) after operation (P < 0.0001). CONCLUSION: Delormes procedure had a low morbidity, did not lead to constipation, improved anal continence, and had a reasonably low recurrence rate. Improved anal sphincter and rectal sensation were associated with a reduced incidence of defecatory problems after Delormes procedure.     

How to Choose the Best Metabolic Procedure?

Bariatric/metabolic surgery has proven to be effective in inducing and maintaining diabetes remission—although with a percentage of patients undergoing hyperglycemia relapse—weight loss, and improvement of the cardiovascular risk. It is, however, associated with mortality, although low, and early and late complications. In particular, metabolic complications are related to vitamin deficiency due to the erratic absorption of the supplemented vitamins and to the unpredictable compliance of patients to vitamin and trace element supplementation. In addition, often, the general practitioners and even the specialists are unaware of the clinical effects of metabolic dysfunction following malabsorptive surgery. The choice of the surgical procedure should be the balance between benefits and risks. Our review addresses this important question trying to give some suggestions.     

Pelvic Sepsis After Extended Hartmann’s Procedure

PURPOSE An extended Hartmanns procedure is occasionally useful in rectal resections, because anastomotic, perineal, and functional problems are eliminated. This study was designed to examine the occurrence of pelvic sepsis after this procedure and identify possible risk factors.METHODS Medical records were available for 163 patients (89 females) undergoing rectal resection with colostomy and closure of the rectal remnant. Information about pelvic sepsis and possible risk factors was obtained by review of the medical records.RESULTS Pelvis sepsis developed in 31 of 163 patients (18.6 percent). When the rectum had been transected <2 cm above the pelvic floor, 24 of 73 patients (32.9 percent) developed an abscess in contrast to 7 of 90 (7.8 percent) after higher transsection (P = 0.0001). Other risk factors were male gender and missing foot pulses. Only 61 percent of pelvic abscesses healed after a median of 59 days, leaving 39 percent unhealed after an observation period of 277 (range, 20–1,643) days.CONCLUSIONS Surgical alternatives should be considered to an extended Hartmanns procedure when the level of transsection is <2 cm above the pelvic floor, particularly in males.Reprints are not available.     

Expanding Eligibility for the Ross Procedure: A Reasonable Proposition?

Background

Although the Ross procedure offers potential benefits in young adults, technical complexity represents a significant limitation. Therefore, the safety of expanding its use in more complex settings is uncertain. The aim of this study was to compare early outcomes of standard isolated Ross procedures vs expanding elgibility to higher-risk clinical settings.

SECCA® Procedure for the Treatment of Fecal Incontinence: Results of Five-Year Follow-Up

Purpose

This study evaluated the long-term (5-year) durability of radiofrequency energy delivery for fecal incontinence.

Methods

This was an extension of the follow-up from our original prospective study in which patients who suffered from fecal incontinence were treated with the SECCA® system for radiofrequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0–20), fecal incontinence-related quality of life score, and Medical Outcomes Study Short-Form 36 were administered to five years. Differences between baseline and follow-up were analyzed by using paired t-test.

Results

A total of 19 patients were treated and followed for five years, including 18 females (aged 57.1 (range, 44–77) years). The mean duration for fecal incontinence was 7.1 (range, 1–21) years. At five-year follow-up, the mean fecal incontinence score had improved from 14.37 to 8.26 (P?50 percent improvement. All fecal incontinence-related quality of life scores improved, including lifestyle (2.43 to 3.15; P?P?P?P?P?Conclusions Significant and sustained improvements in fecal incontinence symptoms and quality of life are seen at five years after treatment with the SECCA® system. This treatment should be considered for patients suffering from fecal incontinence not amenable to surgery and who have failed conservative management.     

Short-Pouch and Low-Anastomosis Duhamel Procedure Results in Better Fecal Control and Normal Defecation Pattern

PURPOSE The purpose of this study was to analyze the long-term outcome of the short-pouch and low-anastomosis Duhamel procedure and to evaluate the quality of life after pull-through. We also tried to answer the questions: Does the modified Duhamel procedure produce fecal continence? Is the quality of life correlated to normal bowel function (1–3 per day) without the use of laxatives?MATERIALS AND METHODS Between January 1993 and January 2002, 53 patients, 44 (83 percent) males and 9 (17 percent) females, who underwent a Duhamel procedure were assessed retrospectively. Of the 53 children, 36 (67.9 percent) underwent a primary Duhamel procedure at our institute (Group A). Seventeen (32.1 percent) patients had a primary Duhamel pull-through and subsequently a stoma before a redo modified Duhamel procedure (Group B). The technical modification was creation of a short rectal pouch of 35 mm, achieving a low colorectal anastomosis 0.5 cm from or on the dentate line. All 53 patients were assessed prospectively by a disease-specific questionnaire. The total score provided a single index of the quality of life associated with fecal continence.RESULTS For Group A (n = 36), the mean period of follow-up was 71.4 ± 29 months. Constipation was seen in four (11.1 percent) patients. In two (5.6 percent) patients there was a mild degree of soiling. Sensation and urge to defecate was intact in 34 (94.4 percent) children who could wait to go to the toilet until it was socially convenient. For Group B (n = 17), the mean period of follow-up was 73.9 ± 31.2 months. Constipation occurred in 17 (100 percent), encopresis in 14 (82.4 percent), and enterocolitis in 15 (88.2 percent) after the primary Duhamel procedure. In comparison, there was complete absence of constipation (100 percent), encopresis (100 percent), and complete resolution of enterocolitis (100 percent) after the redo modified Duhamel (P = 0.001). Continence to solid stools after primary Duhamel was seen in 5 (29.4 percent) vs. 17 (100 percent) after redo modified Duhamel. After the redo modified Duhamel all 17 (100 percent) patients have retained the sensation and urge to defecate and 15 (88.2 percent) can wait to get to the toilet until it is socially convenient. In all 53 patients, the quality of life was good in 86.8 percent (46/53) and correlated directly with fecal continence (r = 0.977). There was no correlation between age of patient and fecal continence (r = 0.597) and rate of fecal incontinence did not decrease with age. Direct correlation was seen with the presence of constipation and the incidence of late onset enterocolitis (r = 0.942).CONCLUSIONS Short-pouch, low-anastomosis Duhamel pull-through procedure results in fecal continence and complete emptying. The above procedure has a positive impact on the quality of life in these children.     

“Pulmonary Slit” Procedure for Preventing Tension on the Left Internal Thoracic Artery Graft

The gold-standard bypass graft to the left anterior descending coronary artery is the left internal thoracic artery harvested with its pedicle. At times, however, the length of the internal thoracic artery is insufficient for distal anastomosis. Different methods of lengthening the internal thoracic artery or of reducing the distance to the anastomosis site have been described, but at times even these may be inadequate. In order to extend the benefits of the left internal thoracic artery graft to more patients, we perform the “pulmonary slit” procedure as described here.Key words: Lung/surgery, mammary arteries/transplantation, myocardial revascularization/methods, thoracic arteries/transplantationThe left internal thoracic coronary artery (LITA) has proved to be the best bypass conduit for anastomosis to the left anterior descending coronary artery (LAD).¹ However, avulsion of the LITA from its anastomosis to the LAD, due to insufficient length of the graft, is a well-documented (if uncommon) sequela.² This disruption can be caused by such factors as dilated cardiomyopathies, or voluminous lungs in association with chronic obstructive pulmonary disease (Fig. 1). Although our surgical unit routinely uses the in situ skeletonized LITA as an LAD bypass graft, even this is at times insufficient to prevent stretching of the LITA by the lungs during inflation. In anticipation of such a situation, we perform the “pulmonary slit” procedure.Open in a separate windowFig. 1 Intraoperative photograph shows hyperinflated lungs.     

Primary Anastomosis or Hartmann’s Procedure for Patients With Diverticular Peritonitis? A Systematic Review

PURPOSE This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis.METHODS This review identified 98 published studies (1957–2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmanns procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity.RESULTS Operative mortality data from patients with diverticular peritonitis undergoing Hartmanns procedure (n = 1,051) were derived from 54 studies. Considering the Hartmanns procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmanns procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmanns procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0–75) percent with an anastomotic leak rate of 13.9 (range, 0–60) percent and a wound infection rate of 9.6 (range, 0–26) percent.CONCLUSIONS Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmanns procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.Reprints are not available.     

Improved Survival After the Ross Procedure Compared With Mechanical Aortic Valve Replacement

Background

It is unclear whether the Ross procedure offers superior survival compared with mechanical aortic valve replacement (AVR).

The Endoventricular Circular Patch Plasty (“Dor Procedure”) in Ischemic Akinetic Dilated Ventricles

Abstract. From 1984 to 2000, 950 Left Ventricular ischemic asynergy (dyskinetic or akinetic) were operated using the endoventricular circular patch plasty technique. This allows to exclude all asynergic areas of the left ventricular wall and reshape the remaining wall. Both morphology and hemodynamic of left ventricle, are improved. Hospital mortality was below 7%. Life expectancy at 10 years reaches 80% if pre-operative L.V.E.F. is above 30%, and end systolic volume index (E.S.V.I.) below 90[emsp4 ]ml, and 60% in L.V.E.F. is below 30% and E.S.V.I. above 90[emsp4 ]ml. L.V.R. by endoventricular plasty has to be considered in the treatment of ischemic congestive heart failure.     

Laparoscopic Cholecystectomy as a Day Surgery Procedure: Is it Safe?—An Egyptian Experience

Background/Aim:

Major surgery performed as a day surgery procedure is not uncommon. The aim of this study is to evaluate the feasibility of day surgery procedures in laparoscopic cholecystectomy (LC).

Patients and Methods:

A total of 210 patients scheduled for elective LC between 2006 and 2008 were included in our study. The mean age was 40.63 years (range, 25 - 70 years). The indication for surgery was symptomatic cholelithiasis confirmed by ultrasonography without clinical or radiological evidence of acute cholecystitis. All patients were informed about the same-day discharge policy and received the postoperative instruction form on discharge. Preoperative work-up included history taking and physical examination in addition to standard laboratory and radiological tests. Patients above 35 years of age had an ECG done. All patients were examined in the outpatient clinic by a consultant anesthesiologist the night before surgery. Operative time, hospital stay, and complications were recorded. Telephonic feedback, on the morning after surgery was routinely done as an early follow-up.

Results:

Out of the total number of patients, 140 patients were ASA (I) and 70 were ASA (II) (40 patients were controlled hypertensives and 30 were controlled diabetics). Conversion rate was 1.4%. The mean hospital stay was 6.7 hours (range, 6 - 8 hours). The mean operative time was 31.2 minutes (range, 20 - 60 minutes). None of the patients required an abdominal drain. No morbidities or mortalities were reported in this series.

Conclusion:

LC may be done as a day surgery procedure with optimal patient satisfaction and without complications.     

Long-Term Results of Delorme’s Procedure and Orr–Loygue Rectopexy to Treat Complete Rectal Prolapse

PURPOSE The aim of this study was to assess long-term outcome of Orr–Loygue rectopexy and Delorme’s procedures in total rectal prolapse management.METHODS Data were collected retrospectively from 1978 to 2001. Statistical analysis was performed by chi-squared test and Student’s t -test.RESULTS One hundred nine patients underwent either a Orr–Loygue rectopexy (49 patients) or a Delorme’s procedure (60 patients). Mean follow-up was 88 (range, 1–300) months. In the rectopexy group, the overall complication rate and the recurrence rate were 33 percent and 4 percent, respectively. In patients with preoperative constipation, this symptom was improved or completely resolved in 33 percent and worsened in 58 percent postoperatively. Seventy-three percent of patients with preoperative incontinence were continent or had continence improvement postoperatively. In Delorme’s group, overall complication and recurrence rates were 15 percent and 23 percent, respectively. Mortality was 7 percent. In patients with preoperative constipation, this symtom was improved or completely resolved in 54 percent and worsened in 12.5 percent of patients postoperatively. Forty-two percent of patients with preoperative incontinence were continent or had continence improvement postoperatively.CONCLUSIONS In this study, Orr–Loygue rectopexy had a lower long-term recurrence rate. However, this surgical procedure is associated with a higher complication rate. We believe that Delorme’s procedure is still a valuable option in selected patients with postoperative minimal morbidity but higher recurrence rate.