Risk factors for surgical site infection after groin hernia repair: does the mesh or technique matter?

Hernia - Surgical site infections (SSIs) following groin hernia repair (GHR) are getting rarer in high income countries despite a wider use of meshes. Among the risk factors for SSIs, those related...     

Abnormal endogenous pain modulation and somatic and visceral hypersensitivity in female patients with irritable bowel syndrome

AIM： To investigate the role of endogenous pain modulatory mechanisms in the central sensitization implicated by the visceral hypersensitivity demonstrated in patients with irritable bowel syndrome （IBS）. Dysfunction of modulatory mechanisms would be expected to also result in changes of somatic sensory function.
METHODS： Endogenous pain modulatory mechanisms were assessed using heterotopic stimulation and somatic and visceral sensory testing in IBS. Pain intensities （visual analogue scale, VAS 0-100） during suprathreshold rectal distension with a barostat, cold pressor stimulation of the foot and during both stimuli simultaneously （heterotopic stimulation） were recorded in 40 female patients with IBS and 20 female healthy controls.
RESULTS： Rectal hypersensitivity （defined by 95% Cl of controls） was seen in 21 （53%）, somatic hypersensitivity in 22 （55%） and both rectal and somatic hypersensitivity in 14 of these IBS patients. Heterotopic stimulation decreased rectal pain intensity by 6 （-11 to -1） in controls, but increased rectal pain by 2 （-3 to ＋6） in all IBS patients （P 〈 0.05） and by 8 （-2 to ＋19） in IBS patients with somatic and visceral hypersensitivity （P 〈 0.02）.
CONCLUSION： A majority of IBS patients had abnormal endogenous pain modulation and somatic hypersensitivity as evidence of central sensitization.     

Tailored therapy for different presentations of chronic pain after stapled hemorrhoidopexy

Background

As stapled hemorrhoidopexy (SH) becomes more widely used, we see more patients with chronic postoperative anal pain after this surgery. Its presentation is variable and difficult to treat. The aim of our study was to investigate the impact of chronic anal pain after SH and whether tailored therapy was likely to achieve a favorable outcome.

Methods

We retrospectively analyzed 31 consecutive patients with chronic anal pain who had undergone SH in other hospitals and were referred to our institutions. Depending on the type of pain, unrelated (at rest) or related to defecation, two groups of patients were identified. Moreover, the mean distance of the staple line from the anal verge was calculated in both groups. Treatments included: topical nifedipine, local anesthetic and steroid infiltration, removal of retained staples, anal dilation, and scar excision with mucosal suturing. A visual analog scale (VAS) was used to compare pain at baseline, postoperatively, and in the follow-up. This mean difference of the VAS score between stages was always used as the main outcome measure, depending on the type of presentation, type of pain, and type of treatment. Treatment response was defined as a 50 % decrease of VAS from baseline.

Results

There were 22 males and 9 females. The overall median age was 43 years (range 21–62 years). On digital examination and proctoscopy, 15 (48 %) patients had inflammatory changes, 19 (61 %) patients had staple retention, 8 (26 %) patients had anorectal stenosis, and 30 (97 %) patients had scar tissue. All patients had one or more of the following treatments listed from the least to most invasive: topical nifedipine in 12 (39 %) patients, anal dilation in 6 (19 %) patients, anesthetic and steroid infiltration in 18 (58 %) patients, removal of staples in 10 (32 %) patients, and scar excision in 18 (58 %) patients. The mean VAS score at baseline was 6.100, ± 1.953 SD, which dropped significantly after treatment to 1.733, ± 1.658 SD (p < 0.001) and remained low at follow-up (1.741 ± SD 1.251; p < 0.743). In patients with pain at rest (n = 20, 65 %), the symptoms improved in 19 (95 %) patients, while the VAS score decreased from 5.552 ± 2.115 SD to 1.457 ± 1.440 SD (95 % CI 3.217–4.964; p < 0.001). In patients with post-evacuation pain (n = 11, 35 %), the symptoms improved in 11 (100 %) patients, while the VAS score decreased from 6.429 ± 1.835 SD to 1.891 ± 1.792 SD (95 % CI 3.784–5.269; p < 0.001). Rating of response based on presentation was 90.0 % (0.9/10) after treatment of staple retention, which led to a significant decrease in the mean VAS score from 6.304 ± 1.845 SD to 1.782 ± 1.731 SD (95 % CI 3.859–5.185; p < 0.001). Anal stenosis was successfully treated in 100.0 % (n = 8/8) of cases with the mean VAS score dropping from 6.500 ± 1.309 SD to 2.125 ± 1.808 SD (95 % CI 2.831–5.919; p < 0.001). Anal inflammation improved in 60.0 % (n = 9/15) of patients and the mean VAS score dropped from 6.006 ± 2.138 SD to 1.542 ± 1.457 SD (95 % CI 3.217–4.964; p < 0.001). The response after scar tissue treatment was 94 % (n = 17/18) of patients with a mean VAS decreasing from 6.117 ± 2.006 SD to 1.712 ± 1.697 SD (95 % CI 3.812–4.974; p < 0.001). Success for topical nifedipine was between 13 and 25 % of patients depending on the clinical presentation. Anal dilation was successful in 75 % of patients, while Anesthetic and steroid infiltration in 23–54 % of patients depending on the clinical presentation. Staple removal was successful in 77 % of patients, and scar excision with mucosal suturing in 94 % of patients.

Conclusions

Our retrospective study suggests that most patients with chronic anal pain after SH may be cured with treatment by applying a stepwise approach from the least to the most invasive treatment.

     

Pudendusneuralgie Anatomisch-chirurgische Aspekte

Anatomie:  

Das Perineum wird hauptsächlich von den Nervi pudendi versorgt. Der Nervus pudendus, ein tiefliegender Dammnerv, durchläuft mehrere Zonen, in denen Kompressionen auftreten können: zwischen dem Ligamentum supraspinatum und dem Ligamentum sacrococcygeum, zwischen dem Ligamentum sacrotuberale und dem Ligamentum sacrospinale, im Alcock-Kanal sowie im Bereich des Musculus obturatorius internus. Eine derartige Kompression kann zu einem Schmerzsyndrom im Dammbereich führen.     

Levator ani and puborectalis muscle rupture: diagnosis and repair for perineal instability

Techniques in Coloproctology - Puborectalis muscle rupture usually arises from peri-partum perineal trauma and may result in anterior, middle compartment prolapses, posterior compartment prolapse...     

Optimizing electrode implantation in sacral nerve stimulation—an anatomical cadaver study controlled by a laparoscopic camera

Background and aim Sacral nerve stimulation is the therapy of choice in patients with neurogenic faecal and urine incontinence, constipation and some pelvic pain syndromes. The aim of this study is to determine the best insertion angles of the electrode under laparoscopic visualization of the sacral nerves. Materials and methods Five fresh cadaver pelvises were dissected through an anterior approach of the presacral space, exposing the ventral sacral roots. Needles and electrodes were inserted into the S3 foramen. Both right and left sides were used, with the traditional percutaneous procedure. The validation was done by a laparoscopic camera controlling the position of the needle and electrode on the nerve. The angles were assessed with a goniometer and were confirmed in two living patients. Results The mean angle of insertion in the sagittal plane was 62.9 ± 3° (range, 59–70). In the axial plane, the mean angle for the left side was 91.7 ± 13.5° (range, 80–110) and 83.2 ± 7.7° for the right side (range, 75–95). These angles resulted in the optimal placement of the leads along the S3 sacral root, in all these cases. Conclusions This study allows direct visualization during the placement of the needle and electrode, thus permitting accurate calculations of the best angle of approach during the surgical procedure in sacral nerve stimulation. These objective findings attempt to standardize this technique, which is often performed with the aid of intra-operative fluoroscopy but still leaving a lot to chance. These insertion angles should help to find more consistent and reproducible results and thus improved outcome in patients. Buchs and Dembe have contributed equally to this work.