Anal incontinence—sphincter ani repair: indications,techniques, outcome

Introduction  Fecal incontinence is a debilitating problem that has many different causes. There also are many treatments options, from behavioral modification to sphincteroplasty to artificial anal sphincter and colostomy. In a society with an aging population, fecal incontinence is an ever-increasing problem and will continue to grow. Discussion  Treatment plans need to be individually tailored for each patient. The surgeon should be proficient in different types of procedures and match the procedure with the needs of the patient. Long-term follow-up of these patients must continue to help us better serve this patient population.     

Epidemiological study of trauma caused by traffic accidents on Hefei—Nanjing expressway

Objective:To analyze the epidemiological data of trauma caused by traffic accidents on Hefei-Nanjing expressway from the year of 1995 to 1996.Methods:The data provided by Anhui Provincial Traffic Police Bureau were analyzed and discussed. Rsults:Mortality rates in 1995 and in 1996 were respectively 0.19 and 0.12 er 10000vehicles.Traffic accidents occurred mostly in fine weather from 22:00 to 6:00.The cause of traffic acidents in the first place was the head-tail collision,then the collision with fixtures or overturning,Traffic accidents bringing about by drivers accounted for more than 70 percent of the cases.The reasons was weary driving,illegal parking and over-speed driving.The breakdown of vehicles and pedestrians on highway were also the cause of accidents.Conclusions:In order to reduce the incidence of traum caused by traffic accidents on expressway,the followings should be carried out as strengthening the policy or traffic administration on expressway,examining strictly vehicles annually,educating drivers to abide by traffic rules,propagandizing people‘s traffic safety consciousness and forbidding pedestrians to walk into expressways.     

Percutaneous vertebroplasty: technical considerations

Percutaneous vertebroplasty (PVP) is a relative new interventional technique, which is widely used in treatment of vertebral collapse caused by vertebral neoplasms and osteoporotie compression fractures. The general technical considerations of PVP techniques are discussed based on authors‘ experience obtained over 400 patients in the past years in this article, including preparation of PMMA, instrument of PVP, guidance and puncture approaches, and technique of the procedure, etc. The conclusion is that PVP is a safe procedure if the physicians handle it properly.     

Anal metastasis of colonic carcinoma?

Two cases of sigmoid and anal adenocarcinoma are reported. The two patients were treated by abdominoperineal resection of the rectum and resection of the sigmoid colon. The relationship between colonic adenocarcinoma and anal adenocarcinoma is not obvious but possible. The various mechanisms of tumoral spread are discussed and the most frequent mechanism seems to be cellular exfoliation.     

Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump

BACKGROUNDThe initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.AIMTo review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.METHODSA systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.RESULTSFor rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.CONCLUSIONThe retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.     

Atropine and glycopyrrolate do not support bacterial growth—safety and economic considerations

Study objectiveEvaluation of bacterial growth in atropine and glycopyrrolate.DesignLaboratory investigation.Subjects and measurementsStandard microbiological methods were used to evaluate the impact of atropine and glycopyrrolate on the growth of Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus, and Escherichia coli. Bacterial count was checked at 0, 1, 2, 3, 4, 6, and 24 hours.Main resultsAtropine or glycopyrrolate did not support the growth of the above bacteria at any examined time at room temperature. Glycopyrrolate killed all of the examined strains (P < .05), whereas in atropine, only the clinical isolates of Staphylococcus and Acinetobacter were killed (P < .05).ConclusionsDrawing up atropine or glycopyrrolate at the beginning of the operating list and use within 24 hours if needed are a safe practice and do not pose infection hazard. We can also reduce hospital costs if we do not throw away these unused syringes following each case.     

Anal Sphincter Repair in the Treatment of Anal Incontinence - When and How to Do it?

Anal incontinence is a disease of high prevalence. For many patients the disease causes severe stress and often results in social isolation. Whenever a sphincter lesion has been diagnosed by digital rectal examination and endosonographic access, anal sphincter reconstruction can be performed with the same results either in overlapping or in end-to-end suture technique. sing these procedures, in more than 60 % of patients the continence can be initially improved. However, benefit decreases after 5 years down to 40-50 %. The prognosis gets worse with increasing age and supplementary descending pelvic floor. Anal repair with reconstruction of internal and external sphincters is performed in neurogenic incontinence. This can be achieved by posterior or anterior anal repair (total pelvic floor repair). Nowadays these procedures are not common, due to unsuccessfulness. Instead, sacral nerve stimulation as a more expensive but less invasive method has displaced the anal repair on this indication. Interpretation of the published results remains delicate because of heterogenous evaluation criteria of postoperative outcome: subjective amelioration, postoperative satisfaction and quality of life, improvement of incontinence score or achievement of complete anal continence. However, it is proven that after immediate reconstruction of traumatic sphincter lesions the postoperative outcome is better than a two-step operation with primary ostomy.     

Anal carcinoma or "just hemorrhoids"?

Cancers of the anal margin and anal canal are extremely rare and often misdiagnosed. Only one to two per cent of large bowel cancers arise in this area. Current management of these cancers includes surgery, combined chemoradiation, or both. From January 1985 through July 2000, 50 patients were diagnosed with anal cancer at two institutions. This retrospective review includes all available cases of anal cancer including all histologies. Patient charts were analyzed for diagnosis, staging, treatment, survival, and recurrence rate. The patients ranged in age from 27 to 92 years (median age 51 years; mean age 52.8 years); there were 22 men and 28 women. The pathologic diagnosis included 44 (88%) with squamous cell carcinoma, three (6%) with melanoma, two (4%) with adenocarcinoma, and one (2%) with Paget's disease. At presentation nine (18%) were classified as stage 0, five (10%) stage I, 21 (42%) stage II, eight (16%) stage III, and seven (14%) stage IV. Mean follow-up data were available on 100 per cent of the patients. Chemoradiotherapy was the primary treatment modality in 25 patients (50%). Ten patients (20%) underwent abdominoperineal resection (APR) in the study. Three patients (6%) received an APR as primary treatment, three (6%) in combination with chemoradiation, and four (8%) for salvage therapy. Fourteen patients (28%) underwent wide local excision (WLE) as the primary treatment. Two patients (4%) underwent WLE plus chemoradiation therapy. One patient (2%) underwent WLE and chemotherapy. There were 18 deaths (36%) in this series. Thirteen patients (26%) died of anal cancer; the average time to death from diagnosis was 13.2 months. Three of these deaths were in patients with melanoma who presented with stage IV disease. Thirty-two patients (64%) are alive, and 30 (60%) of these patients are free of disease (mean time since diagnosis 32.5 months, range 2-151 months). Six patients (12%) had recurrence after treatment (mean time to recurrence 12.6 months; range 3-26 months). Anal cancers continue to present at an advanced stage, with a high mortality rate. Anal melanoma in particular is an aggressive and highly fatal cancer. APR remains the recommended salvage therapy for advanced anal carcinomas that fail primary treatment. In our series only one of four patients has had a disease-free survival of 4 months. Early recognition and detection of primary and recurrent disease is necessary for improved outcome.     

Complex regional pain syndrome type 1 predictors — Epidemiological perspective from a national database analysis

ObjectiveComplex regional pain syndrome type 1 is a disabling pain disorder with unclear etiology. It is usually triggered by an injury to a limb with or without specific nerve injury. The objective of this study is to explore the risk factors and predictors for this disease utilizing a large national database.DesignRetrospective analysis of the Nationwide Inpatient Sample database from 2007 to 2011 in the United States.Setting and patientsAdult inpatients diagnosed with complex regional pain syndrome type 1.Statistical analysisChi-square, simple and multivariate logistic regression analyses were conducted. The regression model was adjusted to the patient's demographics and comorbidities.Main resultsThere were 22,533 patients with the discharge diagnosis of complex regional pain syndrome type 1 of an inpatient sample of 33,406,123. It peaks between age 45 and 55. Female gender, Caucasian race, higher median household income, headache, depression, drug abuse and private insurance patients (vs Medicaid patients) were associated with higher rate of complex regional pain syndrome type 1. On the other hand, diabetes, obesity, hypothyroidism, and anemia were associated with a lower rate.ConclusionsUtilizing a large database, our study added more information to the risk profile of the complex regional pain syndrome type 1 in an inpatient population. Such information should be useful for physician for early recognition, diagnosis of patients at risk.     

Lobular neoplasia: is surgical excision warranted?

The treatment of breast cancer associated with lobular neoplasia detected on core needle biopsy (CNB) remains controversial. The purpose of this study was to review the prevalence of lobular neoplasia in CNB specimens and to correlate CNB pathology to final surgical pathology. Patients with lobular neoplasia were included for analysis in this retrospective review. Patients with concomitant malignant or atypical lesions were excluded. Method of initial diagnosis, clinical history, pathology results, and follow-up data were then analyzed. From January 1994 to December 2005, 5257 CNBs were performed at our tertiary level medical facility. Of patients with lobular neoplasia, 42 of 50 (84%) patients had atypical lobular hyperplasia, whereas 8 (16%) patients were diagnosed with lobular carcinoma in situ on CNB specimens. There were no associated malignancies in 21 patients who underwent immediate surgical excision. Of those patients who were serially followed, four developed malignancies at an average of 73 months after the sentinel diagnosis. Three of the four (75%) malignancies occurred in the ipsilateral breast. Patients with a diagnosis of lobular neoplasia by CNB should not routinely undergo an open surgical biopsy. Lobular neoplasia should only be considered a risk marker for future invasive breast cancer.     

Full facial retransplantation in a female patient—Technical,immunologic, and clinical considerations

There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.     

Anal adenocarcinoma complicating chronic Crohn’s disease

IntroductionColorectal adenocarcinoma and Crohn’s disease are known to be associated entities. However, a carcinoma arising within a chronic perianal fistulous tract in a patient with Crohn’s disease is a rare complication.Presentation of caseWe present a case of a 40-year-old male patient with a long-standing perianal Crohn’s disease who developed an anal mucinous adenocarcinoma within the fistulous tracts.DiscussionAlthough, Crohn’s disease and colorectal carcinoma association is well established, few cases have been reported where the cancer has originated within a perianal fistula. Constant mucosal regeneration occurring within a fistula seems to be the predominant pathogenetic mechanism, while immunosuppressants and anti-TNF agents may also contribute to the malignant transformation. Unfortunately, the lack of suspicion and the inadequate physical examination or colonoscopy due to exacerbation of the perianal symptoms could lead to delayed diagnosis; and thus, a poor prognosis.ConclusionAlbeit a rare complication, clinicians should maintain a high degree of vigilance about the possible development of adenocarcinoma in patients with long-standing perianal Crohn’s disease. Thus, these patients should be kept under regular surveillance with examination under anaesthesia and biopsies or curettage of the tracts.