Rectal advancement flap is an accepted approach for treating complex fistula-in-ano. However, a diversity of technical modifications have been described. The aim of this study was to evaluate recurrence and fecal continence rates after performing rectal advancement flaps depending upon flap thickness (full-thickness, partial-thickness, or mucosal flaps) and treatment of the fistulous tract (core-out or curettage).
Methods
Medline (PubMed, Ovid), the Cochrane Library database, and ClinicalTrials.gov were searched. Studies that involved patients with complex cryptoglandular fistulas who had been treated with rectal advancement flaps were included. The outcomes measured were recurrence and fecal continence. All of the statistical analyses were performed using Comprehensive Meta-Analysis software. A fixed model was used if there was no evidence of heterogeneity; otherwise, a random effects model was used.
Results
Twenty-six studies were included (1655 patients). The pooled rate of recurrence was 21%. Full-thickness flaps showed the best results concerning recurrence (7.4%), partial flaps revealed 19% and mucosal flaps 30.1%. Core-out and curettage had a similar recurrence (19 vs 21%). Regarding anal incontinence, the pooled rate was 13.3%. Mucosal- and partial-thickness flaps showed similar rates (9.3 vs 10.2%), while full-thickness flaps disturbed it in 20.4%. Most of these alterations were minor symptoms. Otherwise, core-out and curettage showed similar rates (14.3 vs 12%).
Conclusions
1. Full-thickness rectal advancement flaps offer better results regarding the recurrence than mucosal or partial flaps. 2. All flaps cause some incontinence, which increases with the thickness of the flap. 3. The results did not suggest differences in recurrence and incontinence between core-out and curettage.
Alterations in urinary function are complications of rectal cancer surgery. The aim of this study was to prospectively analyze the changes in urinary function in patients operated on for rectal cancer, and to identify risk factors that may have an impact on the deterioration of postoperative urinary function.
Methods
A prospective study of urinary function in rectal cancer patients who had elective oncological resection with curative intention at the Arnau de Vilanova Hospital in Valencia, Spain, from January 2017 to March 2019. The evaluation of urinary function was performed using the International Prostate Symptom Score (IPSS) preoperatively, at 6 and 12 months after surgery. Predictive factors of urinary dysfunction were identified by univariate and multivariate analysis.
Results
Ninety-four patients were enrolled in the study. Eighty-seven of them completed all the follow-up assessments (48 men and 39 women, mean age 65.74?±?10.95 years,). The mean IPSS was 7.96?±?7.59 preoperatively, 9.01?±?6.81 at 6 months, and 8.63?±?5.59 at 12 months, without statistically significant differences. There were no differences in IPSS between males and females. Preoperative urinary dysfunction was 39% and at 12 months, a deterioration occurred in 23 patients (26.4%). IPSS analysis of symptoms showed a statistically significant worsening of nocturia at 6 months (p?=?0.002) and 1 year after surgery (p?=?0.037) in women. American Society of Anesthesiologists (ASA) class (OR: 11, [95% CI2.4–53]; p?=?0.010), surgical difficulty (OR: 4.5, [95% CI 1–19]; p?=?0.027) and anastomotic leakage (OR: 14, [95% CI 1.6–117]; p?=?0.010), were identified as independent risk factors for deterioration of urinary function after surgery.
Conclusions
Our study showed worsening urinary dysfunction after rectal cancer surgery in 26.4% of the patients. However, there were no statistically significant differences in mean IPSS scores at the three assessment times (preoperatively, 6 months, 12 months). ASA class, surgical difficulty, and anastomotic leakage may predict postoperative deterioration.
Aim The study evaluated the rate of reversal of Hartmann’s operation after the initial surgery and its morbidity. Method A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann’s operation from 2004 to 2008. The incidence of reversal was determined. Results Four hundred and fifty‐two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann’s procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD. Conclusion Hartmann’s reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity. 相似文献
Transanal endoscopic surgery with conventional laparotomy materials may be an alternative to transanal endoscopic microsurgery (TEM) for the excision of rectal lesions susceptible to local resection.
Material and method
We prospectively analysed 27 patients included consecutively between 1999 and 2009, on whom a Transanal endoscopic operation (TEO) was performed by total resection of the rectal wall. All procedures were performed with a 40 mm rectoscope, initially designed by us and later with the Storz rectoscope, using conventional laparoscopic tools and material.
Results
We operated on 27 patients with a mean age of 69.4 years: 23 due to benign lesions and 4 malignant. The medium distance of the tumour to the anal margins was 8.2 cm (range 5-15) and a mean tumour diameter of 3.38 ± 1.2 cm. There were 4 postoperative complications, 3 due to bleeding and one case of perforation. The mean hospital stay was 6 ± 3.75 days. There was no perioperative mortality or recurrences..
Conclusion
Performing transanal endoscopic surgery with conventional laparoscopy material is feasible, with a reduction in costs and accessible to laparoscopy surgeons. 相似文献
Aim Treatment of giant condyloma acuminatum, is controversial, especially in human immunodeficiency virus (HIV)‐positive patients, owing to concern over wound healing, complications, risk of progression to carcinoma and a high recurrence rate. The aim of this study was to evaluate the outcome after extensive local excision with V–Y anoplasty. Method Nine patients were identified from a prospective database, six of whom were HIV positive. All patients had a giant perianal condyloma acuminatum extending into the anal canal and perianal region, which required wide excision with V–Y reconstruction. Postoperative complications, recurrence and continence were all determined. Results Nine patients were included (eight men, median age 40 years), six seropositive for HIV infection. A bilateral V–Y anoplasty was performed in six patients, and unilateral in two. There were no postoperative infections, graft failures or flap necrosis. The mean follow‐up was 92 (2–137) months. One patient developed local recurrence treated with excision under local anaesthesia. Conclusions Extensive local surgery of giant perianal condyloma with anoplastic reconstruction gives good results even in HIV‐positive patients. 相似文献
