No Surgery for Full-Thickness Rectal Prolapse: What Happens with Continence?

Background

Surgery is the only validated means of treating overt rectal prolapses, but both patients and physicians may decline or postpone the surgical approach. However, little is known on the functional outcome of nonoperated rectal prolapse. The aim of the present study was to highlight the natural history of overt rectal prolapse in patients for whom surgery was avoided or delayed.

Patients and methods

A total of 206 patients complaining of full-thickness rectal prolapse were referred to a single institution that provided anorectal physiology for functional anorectal disorders. Standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography constituted a prospective database. Fecal incontinence was evaluated with the Cleveland Clinic score (CCIS), and constipation was evaluated with the Knowles Eccersley Scott Symptom score (KESS).

Results

Forty-two nonoperated patients (mean age: 61 ± 16 years) were compared to those of operated patients paired according to age and gender: the mean follow-up was 44 ± 26 months. The two groups had a similar past-history, follow-up, stool frequency, and main complaints, but lower quantified symptomatic scores and a better quality of life were reported in the nonsurgical group. At the end of follow-up, the nonsurgical group did not show any variation in CCI and KESS scores. By contrast, these two scores significantly improved in the rectopexy group. Sixteen nonoperated patients experienced a degradation of their continence status with an average increase of 5 ± 4.3 points of the CCIS. The patients with a CCIS <7 at referral were likely to deteriorate as compared to those having a higher score. Patients with a symptom history longer than 4 years never improved and in two-thirds continence deteriorated throughout the follow-up.

Conclusion

In the absence of the surgical option, patients with a 4-year duration of rectal prolapse and those with mild incontinence had no chance of improvement. These findings may be taken into account when surgery of rectal prolapse is not chosen.     

Laparoscopic Rectopexy for Rectal Prolapse: Will it be the Gold Standard?

A review of the current literature is presented regarding the surgical management of full thickness rectal prolapse, comparing laparoscopic rectopexy with open abdominal operations and perineal procedures. Outcome measures include length of stay, short- and long-term outcomes and financial burdens. Current evidence suggests that laparoscopic rectopexy as treatment for full thickness rectal prolapse is a safe alternative to the other options.     

Sever’s disease—Does it effect quality of life?

BackgroundSever’s disease is a condition which has been described inconsistently in the literature with respect to pathology, aetiology and management. In particular, the impact of this condition has been overlooked, probably because it is usually self-limiting.MethodThis study used a prospective comparative design study to determine the impact of Sever’s disease on the quality of life of its sufferers.ResultsThree scales – Happiness, Satisfaction with symptoms and Pain/comfort scale – from the POSNA musculoskeletal questionnaire showed significant differences between the symptomatic and control groups.ConclusionAlthough the condition may resolve with time, these results show that it has a considerable impact on children’s lives.     

Outcomes of Laparoscopy Combined with Enhanced Recovery Pathway for Reversal of Hartmann’s Procedure

The objective of this study is to discuss the security and feasibility of the laparoscopic reversal of Hartmann’s procedure (LRHP) on the concept of enhanced recovery after surgery (ERAS). The clinical data of 42 patients who underwent laparoscopic reversal of Hartmann’s procedure was retrospectively analyzed, and the operative time, blood loss, intraoperative and postoperative complications, conversion to open surgery, postoperative hospital stay, and so on were observed. Twenty-nine patients (69.00 % of the study pool) received complete postoperative recovery courses as prescribed by enhanced recovery program (ERP). The postoperative length of stay (LOS) in the hospital was 5.6 (3–16 days). The overall and major (grades III to V) postoperative morbidities were 33.3 % (n?=?14) and 4.8 % (n?=?2), respectively. Our preliminary results showed that using the laparoscopic technology in reversal of Hartmann’s colostomy on the concept of ERP is safe and feasible. Patients with intra- or postoperative complications were found to have statistically significant associations with greater risk of ERP failure.     

Does Impaired Gallbladder Function Contribute to the Development of Barrett’s Esophagus and Esophageal Adenocarcinoma?

Introduction  

Esophageal adenocarcinoma is aetiologically associated with gastro-esophageal reflux, but the mechanisms responsible for the metaplasia–dysplasia sequence are unknown. Bile components are implicated. Impaired gallbladder function may contribute to duodenogastric reflux (DGR) and harmful GERD.     

Anorectal malformation & Hirschsprung’s disease: A cross-sectional comparison of quality of life and bowel function to healthy controls

Background

Patients with anorectal malformation (ARM) and Hirschsprung’s disease (HD) face long-term disturbance in bowel function even after definitive surgery. This study evaluates the quality of life (QOL) of patients with ARM and HD, and compares them to healthy controls using self-report questionnaires.

The modified Kocher criteria for septic hip: Does it apply to the knee?

Background:Pediatric septic arthritis is a surgical emergency and timely diagnosis prevents serious complications. To differentiate between septic hip and transient synovitis, the predictive value of four original Kocher criteria (fever, inability to bear weight, elevated serum white blood cell count, and elevated erythrocyte sedimentation rate) plus Caird’s addition of elevated C-reactive protein have been studied, termed the modified Kocher criteria. These criteria have not been tested extensively on septic knee. This study tested the utility of the modified Kocher criteria in predicting septic knee while validating it for septic hip.Methods:A retrospective chart review was conducted of pediatric patients evaluated at a single institution for irritable hip or knee between 2009 and 2018. Patients who underwent arthrocentesis were included and the modified Kocher criteria were applied to all.Results:One hundred fifty-five patients (96 hips and 59 knees) were identified. One hundred four (67.1%) patients had septic arthritis with 44/59 (74.6%) of knees and 60/96 (62.5%) of hips. The strongest predictors for septic hip and knee were elevated C-reactive protein (odds ratio = 26.9, p < 0.0001) and refusal to bear weight (odds ratio = 14.5, p < 0.0001), respectively. For hips, 5/5 criteria produced a 100% positive predictive value for septic arthritis. For knees, the combination of inability to bear weight and elevated C-reactive protein had a positive predictive value of 89.7%.Conclusion:While all five of the modified Kocher criteria are not predictive of pediatric septic knee, the combination of two specific factors (inability to bear weight and elevated C-reactive protein) is strongly predictive. This study validates previous work that the modified Kocher criteria are predictive of septic hip.Level of evidence:level III     

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann’s Procedure? A Case-matched Control Study

Background The optimal treatment remains controversial for acute left-sided colon perforation. Therefore, the effectiveness and safety of primary anastomosis versus Hartmann’s operation (HP) was compared in a case-matched control study. Methods Thirty consecutive patients with primary anastomosis and protective ileostomy (PAS) were matched to 30 HP patients, controlling for age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and peritonitis severity (Hinchey). In a second analysis, PAS patients with purulent peritonitis (Hinchey 3) were matched to patients with primary anastomosis without ileostomy (PA). Results Hospital mortality was similar between HP (17%) and PAS (10%). Complication frequency and severity (requiring re-intervention or admission to the Intensive Care Unit [ICU]) were comparable for the first operation (60% versus 56% and 30% versus 32%). The stoma reversal rate was higher in PAS than in HP (96% versus 60%, p = 0.001), with significantly fewer complications (23% versus 66%, p = 0.02), and lower severity (7% versus 33%, p = 0.02). Additional analysis of PAS versus PA showed similar morbidity (52% versus 41%, p = 0.45) and complication severity (18% versus 24%, p = 0.51), whereas overall operation time and hospital stay were significantly shorter in PA (169 versus 320 min, p = 0.003, 17 versus 28 days, p < 0.001). Conclusions Primary anastomosis and protective ileostomy is a superior treatment to HP in acute left-sided colon perforation. In the absence of feculent peritonitis an ileostomy appears unnecessary. Presented at the 13th Annual Meeting of the European Surgical Association (ESA), Zurich, 2006.     

The Amount of Neoadjuvant Chemotherapy for Barrett’s Carcinoma Does Not Correlate with Long-Term Survival

Introduction  

Several studies have proven an ameliorated prognosis after a neoadjuvant therapy for locally advanced Barrett’s carcinoma in case of response. The necessary amount of neoadjuvant chemotherapy within a multimodal therapy concept with following oesophageal resection has never been evaluated so far.     

Living Donor Liver Transplantation Combined with Whipple’s Procedure for Metastatic Gastrinoma: a Clinical Case with 5 Years Follow-Up

Introduction: Most patients with gastro-enteropancreatic neuro-endocrine tumours present with liver metastases at the time of diagnosis. As metastases are usually widespread in the liver, though remain confined to this organ for long periods of time, liver transplantation could be in some cases a possible treatment option. Material and methods: We herein report the case of a 24-year-old male with Zollinger-Ellison syndrome, who was referred to our department after having had a right hepatectomy for metastatic lesions, followed by chemotherapy. At that time, the site of the primary tumour was undefined. Following the diagnosis of a primary gastrinoma in the pancreatic head after selective angiography of the pancreatic vessels with hormonal sampling tests in our institution, the decision was made to offer a living donor liver transplantation (LDLT).

Results: A right lobe LDLT was carried out together with a Whipple’s procedure. The operation was uneventful and five years later the patient remains in an excellent clinical condition, although with a suspicion of relapsed gastrinoma. Discussion: according to the literature, some conditions, such as the 1-step combined surgery, gastrinoma primary tumour and duodeno-pancreatical localisation are considered as poor prognostic factors, whereas young age and tumour expression of Ki-67 < 5% are linked to a more favourable outcome. We think that in cases of long-lasting stability of the disease under chemotherapy, together with the presence of a low Ki-67 expression index, such a treatment could be proposed to young and symptomatic patients, provided the resection of the primary tumour is feasible. Long-term survival may be achieved in metastatic gastro-enteropancreatic neuro-endocrine tumours after LDLT combined with Whipple’s procedure, despite tumour relapse.     

Some machine’s doin’ that for you* – elektronische Triagesysteme in der Notaufnahme

Notfall + Rettungsmedizin - In den letzten 25&nbsp;Jahren haben sich Triagesysteme zur Dringlichkeitseinschätzung in den Notaufnahmen etabliert. Die bisherigen symptomorientierten...     

The role of testosterone in men’s health: is it time for a new approach?

Purpose

Because of many unanswered questions regarding men’s health, a literature review was performed to better understand the role of testosterone and testosterone replacement therapy (TRT) in the management of hypogonadism and aging related prostate gland diseases (ARPGD) including prostate cancer (PCa) and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS).

Methods

The PubMed database was screened for pertinent peer reviewed articles published during the last four decades that culminated in the positions and recommendations in this paper.

Results

Hypogonadism seriously impacts men’s health, and the diagnosis remains controversial. The incidence of ARPGD is projected to increase worldwide and treatment still has significant limitations. There is compelling evidence that lower, not higher, testosterone levels trigger the development of PCa and BPH through androgen receptor over-expression. TRT was found to be safe and effective in treating hypogonadism including in PCa survivors and those harboring PCa. There is also evidence that TRT might reduce the incidence and prevalence of ARPGD.

Conclusions and recommendations

This review synthesizes a wide-ranging compendium of basic science and clinical research that strongly encourages altering the present approach to diagnosing and treating men with hypogonadism and ARPGD. These findings underscore the importance of avoiding significant testosterone decline and support the use of TRT. Ten recommendations are offered as a framework for the way forward. It is now time for clinicians, payers, researchers, funding agencies, professional associations, and patient advocacy groups to embrace this new paradigm to increase longevity and improve the quality of life.

     

Subtotal Thyroidectomy for Benign Multinodular Goiter: A 6-Month Postoperative Study of the Remnant’s Function and Sonographic Aspect

Background The purpose was to evaluate the thyroid function after subtotal thyroidectomy. Methods One hundred and nineteen patients operated on for multinodular benign goiter were included in this prospective study. Results of the surgical treatment were evaluated 6 months after operation by thyroid-stimulating hormone (TSH) assay and cervical echography. Results Thyroid-stimulating hormone levels correlated inversely (r = −0.78) with the thyroid remnant volumes. Forty-seven patients presented with a hypoechoic aspect of the remnant. Isoechoic and hypoechoic remnant volumes were similar; however, 46 of the 47 patients with a hypoechoic remnant (97.9%) had TSH levels higher than 5 mU/l vs. 39 of the 72 patients (54.2%) with an isoechoic aspect. No predictive factor for the occurrence of this hypoechoic feature was found. Conclusions After sub-total thyroidectomy for benign multinodular goiter, the volume of the remnant is not the only determinant of the occurrence of postoperative hypothyroidism. The appearance of a hypoechoic aspect of the remnant is also a strong predictive factor for such an outcome. In this case the occurrence of hypothyroidism is quite constant whatever the volume of the thyroid remnant. Since this evolution toward a hypoechoic aspect of the remnant is unpredictable, our results are an additional argument in favor of total thyroidectomy for benign multinodular goiter.     

Training tomorrow’s surgeons: what are we looking for and how can we achieve it?

The aim of a surgical residency program is to produce competent professionals in a safe and pedagogically efficient environment. For many years, there has been an overemphasis on technical attributes as the fundamental competencies of a trained surgeon. With the advent of new frameworks for defining the outcomes of surgical training, such as CanMeds from the Royal College of Physicians and Surgeons of Canada and the six competencies outlined by the Accreditation Council for Graduate Medical Education in USA, there has been a broadening of the focus of surgical training. Although technical proficiency is definitely an important prerequisite for a successful outcome, other qualities such as intellectual abilities, personality and communication skills, and a commitment to practice are important elements in the profile of a competent surgeon. Recently, there is a growing appreciation for the heterogeneity in achievement of technical competence among our trainees, with some residents able to quickly master technical skill in contrast to others who may never achieve mastery in the technical domain. The questions of how to select, teach and grant privileges for independent practice requires an understanding of the components of surgical competence and implementation of evidence based tools for training and assessment of these competencies.