Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience

Introduction and hypothesis

Obstetric anal sphincter injuries (OASIs) are associated with significant short-term and long-term morbidity. Over the past decade, there has been a steady rise in the rate of OASIs. There is therefore a compelling need to identify strategies to minimize OASIs. The objective of this study was to determine if perineal support at the time of vaginal delivery can reduce the incidence and severity of OASIs.

Methods

All labour ward staff including midwives and doctors were invited to train in the technique of perineal support during vaginal delivery. Two experts from Norway conducted workshops with practical hands-on training on pelvic models. The midwives and doctors underwent further training with women in labour, and mandatory training was continued within the department. All midwives and doctors were instructed to support the perineum during both spontaneous and assisted vaginal delivery.

Results

From April 2011 to November 2014, 11,135 women underwent vaginal delivery. The OASI rate decreased from 4.7 % to 4.1 % (p?=?0.11). There was a significant reduction (0.9 % to 0.3 %, p?<?0.001) in 3c third-degree and fourth-degree tears (major OASIs). In a multivariate analysis, perineal support was associated with a significant reduction in the rates of OASIs (23 %; OR 0.77, 95 % CI 0.63 – 0.95, p?=?0.01]) and major OASIs (71 %; OR 0.34, 95 % CI 0.17 – 0.69, p?=?0.03).

Conclusions

This interventional study showed that perineal support during vaginal delivery can reduce the risk of major OASIs. With sustained reinforcement of this intervention programme, we anticipate a further reduction in OASI rates.

     

Disposable isostatic anal retractor: results of a clinical assessment

In this paper the authors present the technical characteristics and clinical results of a new anal retractor designed and produced by them. This new instrument, made of disposable material, allows the proctologist to operate completely alone thanks to a system of rotating rings which are fixed directly to the patient's legs by means of Velcro bands. Twenty consecutive patients with proctological diseases have been operated on to date with the new device. No complications were registered in our series. The rotation movement and overall stability of the retractor were judged sufficient in 6 cases and good in 14. Opening of the device proved asymmetrical in 20% of the cases without this affecting the surgical technique. Our surgical team considered the prototype ideal, and the operative space available to the surgeon much greater than with previous retractor models. No limitations have been observed in treating any of the proctological diseases. The possibility of performing sutures in the anal canal was judged to be good. In conclusion, our new anal retractor would appear to guarantee greater autonomy in proctological surgery with much better clinical and therapeutic results and lower costs.     

A new accessory for the isostatic anal retractor

The authors present the characteristics and the advantages deriving from the use of a new accessory to be fitted on the isostatic anal retractor in order to further improve visualisation of the operative field during the treatment of pelvic and anal pathologies. The isostatic anal retractor consists of a system of rotating rings and valves which are positioned with surgical stitches on the patient's buttocks. The new accessory is characterised by one or more elastic systems that can be fixed to the retractor metal ring and attached by means of curved needles to flaps of anal mucosa, affording enhanced visibility of the operative field. A total of 25 patients--15 with mucosal prolapse, 5 with haemorrhoids and 5 with anal fistulas--were treated surgically for their respective pathologies using the isostatic anal retractor and the new accessory. None of the patients observed complained of complications related to the use of the anal retractor or the accessory. In 95% of patients submitted to the procedures using the new accessory, visualisation of the operative field was improved as compared to the use of the anal retractor alone. In 5 patients it was possible to use the new accessory advantageously applied only to the external ring of the retractor. Our operative team judged the use of new accessory to be satisfactory in all cases in which greater visibility of the operative field is required. Use of the new accessory use in association with the isostatic anal retractor proved efficacious for achieving better therapeutic results with the treatments performed, permitting greater operator autonomy and enhancing visualisation of the operative field with respect for sphincter function.     

New abdominal retractor

Infection of the distal phalanx undergoing necrosis with complete destruction of the diaphysis and even as much as seven-eighths of the epiphysis involved, will have a tendency to go on to complete bone restoration of the phalanx, if suitable drainage is instituted and sequestra removed.The removal of sequestra hastens restoration; the non-removal will cause delay in waiting for them to be discharged from the wound, and may destroy neighboring healthy tissue.The diaphysis bears the brunt of the necrosis, being within the upper four-fifths of the phalanx (closed space) while the epiphysis which is in the lower one-fifth does not, being outside the closed space.A horseshoe incision at tip of finger not extending below the upper four-fifths of the phalanx is the incision of choice.Necrosis in a mild case does not necessarily call for curretting for improvement.While the receding of the flaps made by the horseshoe shaped incision may dwarf the growth of the phalanx, sufficient packing will prohibit this.     

Vascularized anal autotransplantation model in rats: preliminary report

Ostomy has served as an effective surgery for various anorectal disfunctions. However, it must also be noted that those patients suffered greatly from stresses caused by their stoma. Many alternative therapies have been developed, but none have solved this critical issue. Meanwhile, due to the improvements in operative methods and immunosuppressive therapy, allotranplantation has gained great popularity in recent years. Therefore, we began development of an anal transplantation model. The operation was performed in six adult Wistar rats that were divided into two groups. Group 1 underwent vascular anastomoses, while group 2 did not Group 1 grafts survived, fully recovering anal function. However, many of the group 2 grafts did not survive; those that did survive showed major defects in their anus, never recovering anal function. We succeeded in establishing the rat anal transplantation model utilizing super-microsurgery. While research in anal transplantation was behind compared to that in other fields, we hope that this model will bring significant possibilities for the future.     

Complex anal fistula surgery: personal experience

Personal experience with the treatment cryptogenic complex anal fistulas over the 10-year period from 1993 to 2002 is reported. Such fistulas accounted for 54 out of 255 fistulas observed (21.1%). Accurate anatomo-pathological classification, based on the connections between the fistulas and the sphincter and the musculature of the pelvic floor, is mandatory, as is thorough preoperative evaluation of ano-rectal function and of the risk of faecal incontinence. The surgical strategies used, in relation to the different kinds of complex fistulas treated, are schematically reported. A mixed technique consisting in fistulectomy-fistulotomy with setons was particularly preferred, because of the risk related to immediate dissection of the sphincter, especially when concurrent risk factors are present. As regards the results obtained, the surgical outcome consisted in healing in 49/54 cases (90.7%) as against recurrence or persistence of the fistula in 5/54 (9.3%). Minor complications occurred in 6/54 (11.1%); no major complications were observed and no cases of permanent faecal incontinence were reported. In conclusion, the surgical choice in cases of complex fistulas must lead to definitive, radical treatment of the lesion, at the same time avoiding irreversible anal incontinence due to severe lesions to the sphincter.     

Basiliximab in lung transplantation: preliminary experience

BACKGROUND: Basiliximab is a chimeric anti-interleukin-2 monoclonal antibody that has shown safety and efficacy in the prophylaxis of acute organ rejection in renal, liver, heart, and kidney-pancreas transplantation (Tx). The aim of this study was to present our initial experience with the use of Basiliximab in lung Tx. METHODS: Basiliximab (2 doses of 20 mg on day 0 and day 4) was administered to 16 patients treated with cyclosporine, azathioprine, and steroids between September 13, 2001 and August 26, 2003, including 12 men and 4 women patients with a mean age of 56.5 years (range, 19-69). The indication for use in transplantations were: reduced renal function (n = 14), post-Tx acute renal failure (n = 1) and steroid-resistant acute rejection (n = 1). Eight double-lung and eight single-lung Tx were performed for emphysema (n = 6), idiopathic pulmonary fibrosis (n = 7), silicosis (n = 2), and cystic fibrosis retransplantation (n = 1). RESULTS: The incidence of acute rejection was 16.6% (2 patients). Infections included cytomegalovirus (CMV) 33.3% (n = 4), bacterial 16.6% (n = 2), and fungal 8.3% (n = 1). Two patients died in the postoperative period and another at 3 months. There was no reaction to the medicine, and no malignancies or Bronchiolitis Obliterans Syndrome (BOS) during a follow-up period of more than 1 year in 10 patients. CONCLUSION: Basiliximab appeared to reduce the incidence of acute organ rejection and showed a good safety profile in terms of infections and adverse events.     

Laparoscopic pancreatic resection: preliminary experience

The aim of the study was to evaluate the results of laparoscopic pancreatectomy for pancreatic tumours. Four women and three men underwent laparoscopic pancreatectomy and were recruited into the study retrospectively over the period from June 2002 to February 2004. Pancreaticoduodenectomy (n = 4), intermediate pancreatectomy (n = 1) and distal pancreatic resection with splenectomy (n = 2) were successfully performed. Operative mortality was nil. The postoperative morbidity included two low-output pancreatic leaks. Mean operating time, blood loss and hospital stay were 342 minutes, 289 mL and 14 days, respectively. The pathological diagnosis was ductal adenocarcinoma in one, neuroendocrine tumour in five and metastatic melanoma in one. All patients are still well after a median follow-up of 7 months (range: 1-20 months). The patients appear to benefit from laparoscopic pancreatectomy for pancreatic tumours. The minimally invasive approach ensures adequate treatment but requires the expertise of highly skilled laparoscopic surgeons.     

Surgical treatment of anal incontinence--a preliminary report

Six patients with anal incontinence were treated operatively at two Finnish proctological centres: 3 patients with post-anal repair, 2 with direct sphincter repair and 1 with a gracilis sling operation. In short term, improvement of continence was demonstrated in all cases both clinically and by manometric measurements; 5 out of the 6 patients are acceptably continent after surgery. The present techniques of surgical treatment of incontinence can offer gratifying results. Anal manometry is a valuable means in the evaluation of these patients before and after the operation.     

Transoral endoscopic thyroidectomy: preliminary experience in Italy

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO₂ insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59–118) min for lobectomy and 107.6 (99–135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.     

2 years experience with the Octopus universal retractor holder]

On 978 operations of all fields of surgery, the new automatic retractor holder has been successfully used. The holder arms are provided with three joints and can be secured in any desired position to keep the edges of the incision and organs in the necessary situation for operating. All joints are locked by operating the central pivot. The advantages of this new automatic retractor holder was described.     

New self-retaining retractor to facilitate surgical exposure

This new self-retaining retractor has blunt prongs that grip firmly but cause minimal trauma. A widely curved arc permits wide separation of the blades. Because the retractor is relatively long and heavy, it sits snugly within the wound, and the base is out of the surgical field. The extra length of the instrument permits considerable upward retraction of the central blade.     

Bioprosthetic plugs for complex anal fistulas: an early experience

PURPOSE: The goal in the treatment of anal fistulas is to eliminate the fistula without a change in continence. No single technique exists that is appropriate for the treatment of all fistulas. Options include fistulotomy, use of setons, fibrin sealant, and advancement flaps. Recently, a bioprosthetic fistula plug has been described. The purpose of this study is to report the author's early experience with the bioprosthetic fistula plug and to compare the results of bioprosthetic plug closure of complex anal fistulas with those achieved with advancement flap repair. METHODS: A retrospective analysis of prospectively collected data was performed for patients treated with an anal fistula. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, procedure performed, pain scores, and fistula recurrence. RESULTS: Overall, 95 patients comprised the control group (43 men and 52 women), with transsphincteric or rectovaginal fistulas in 51 and 44 patients, respectively, managed by advancement flap repair of their fistula. The fistula recurred in 31 patients (32.6%) during a median follow-up of 10 months. Overall,18 patients had their fistula managed using the porcine fistula plug (12 men and 6 women), with transsphincteric or rectovaginal fistulas in 13 and 5 patients, respectively. The fistula recurred in 2 patients (12%) during a median follow-up of 6 months. CONCLUSION: Use of a porcine fistula plug for the management of complex anal fistulas is a new technique that, in the early experience, seems to yield results similar to advancement flap repair.     

Sclerotherapy for esophageal varices: preliminary experience

There has been a resurgence of interest in injection sclerotherapy as a means of controlling and preventing variceal hemorrhage. This report reviews and evaluates the early experience with this procedure at the Toronto General Hospital. From May 1979 to January 1983, 39 patients underwent 73 separate treatment sessions (rigid 23, flexible 50), during active bleeding (3), during hospitalization for variceal hemorrhage but after cessation of bleeding (35) and during elective admission to hospital expressly for sclerotherapy (35). Follow-up was obtained for 38 patients (98%). The overall rate of rebleeding was 27%. Complications occurred in 13 patients (33%). Ten patients died; in 2, death was directly attributable to a complication of sclerotherapy. From this preliminary experience the authors conclude that complications of sclerotherapy are frequent and potentially life-threatening, so more prospective randomized trials are needed before its role in the treatment of bleeding varices is clear.     

Tc-NGA imaging in liver transplantation: preliminary clinical experience

Technetium-99m galactosyl-neoglycoalbumin (Tc-NGA) is a new liver imaging agent that binds to hepatic-binding protein, a hepatocyte-specific membrane receptor. The purpose of this study was to determine the potential of Tc-NGA imaging in clinical liver transplantation. A total of 25 studies were performed in nine patients. Imaging studies performed in the early posttransplant period in patients with good hepatic allograft function revealed diffuse patchiness in tracer distribution, a manifestation of preservation damage. Left lobar infarction was demonstrated within a few hours of ischemic injury. Right posterior segmental infarction was seen in another patient. Comparison of kinetic, clinical, and biochemical data revealed good correlation between hepatic allograft function and Tc-NGA kinetics. Major kinetic alterations were noted during periods of preservation injury, hepatic infarction, and acute rejection. These studies indicate: (1) major alterations in Tc-NGA kinetics occur during preservation injury, hepatic infarction, and acute rejection, and (2) Tc-NGA kinetic data appear to provide an accurate reflection of hepatic allograft function. Tc-NGA imaging has the advantages of being noninvasive and of utilizing standard nuclear medicine instrumentation, including portable imaging devices. In conclusion, Tc-NGA imaging provides a promising noninvasive approach for evaluation of liver function in patients undergoing hepatic transplantation.     

Pancreas graft drainage in recipient duodenum: preliminary experience

Pancreas graft survival has continuously improved over the years to become a main treatment option of uncontrolled complicated diabetes. Rejection remains the major challenge as it often goes unnoticed until severe damage of the graft manifests itself by elevated blood sugar. Pancreas enzymes monitoring in the blood and in the urine is a sensitive marker of rejection but lack of specificity. Biopsy remains the gold standard. Cystoscopy-guided biopsy of bladder-drained pancreas has a good success rate for obtaining tissue but the vesical drainage exposes to metabolic and urologic morbidity. Percutaneous pancreas biopsy can be performed with a low morbidity rate but severe complications can occur. We discuss a technique of pancreas transplantation with the drainage of exocrine secretions of the pancreatic graft in the recipient duodenum, which permits easy monitoring of the graft by upper endoscopy of the duodenum.     

New self-retaining retractor holder to facilitate surgical exposure

A new self-retaining retractor holder has been developed which is so simple in design that no additional expensive, cumbersome or complicated equipment is needed. It invaginates the sterile draping to hook onto a standard ether screen in any position desired. It holds most standard retractors and can be quickly applied, repositioned or removed without breaking sterility. It will provide simultaneous forceful and gentle retraction. It is extremely versatile. An extra ether screen appropriately applied to the operating table will provide support for multidirectional cervical, thoracic, abdominal or perineal exposure. The retractor holder greatly reduces the need for extra operating room personnel.