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Development and status of proctology in Japan.

Formerly in Japan, the treatment of anal diseases was performed with techniques transmitted from Asian countries such as China and Korea using herbs, necrotizing agents, ligation, seton, and other methods. Before World War II, western medicine and techniques were brought in from Germany, including Whitehead's operation. After the war, new knowledge was introduced from the United Kingdom and the United States: ligation and excision for hemorrhoids, sphincter-preserving methods such as Hanley's and Parks' for fistulas, and sliding skin graft methods such as Carmels' for anal fissure. After their introduction, those methods were revised and improved in Japan. Unfortunately, however, the results of those improvements were not introduced to other countries in medical journals or in presentations at international conferences. At this time, I am honored to give an overview of proctology in Japan for this special Japanese issue.

Colonic Diseases↗

The use of relaxation techniques in the perioperative management of proctological patients: preliminary results.

Relaxation techniques positively affect the psychosomatic pattern of patients undergoing surgical treatment. Among these techniques guided imaging (GI) has been reported to improve outcome following colorectal surgery. This study assessed the effects of GI on the postoperative course in proctological patients. We carried out a prospective randomized trial in a group of patients operated on for anorectal diseases in our coloproctology unit. Patients were randomized into group 1 (n = 43) with standard care and group 2 (n = 43) with relaxation techniques; they listened to a GI tape with music and relaxing text before, during, and after surgery. The following parameters were evaluated by a questionnaire (a) postoperative pain measured by visual analogue score, (b) the quality of sleep measured by a similar score, and (c) the nature of first micturition, evaluated as normal or difficult. Groups were similar in age and sex distribution, type of disease, and operation performed. The pain score was 3.2 +/- 1.4 in GI patients and 4.1 +/- 2.1 in controls (P = 0.07). The quality of sleep score was 4.8 +/- 2.9 in GI patients and 6.4 +/- 2.7 in controls (P = 0.01). The first micturition was painful in 10.3% of GI patients and in 27.3% of controls (P = 0.09). Perioperative relaxation techniques thus showed a trend to reducing pain following anorectal surgery and significantly improving the quality of sleep; a decrease in anxiety and a consequent muscle relaxation may be involved. Therefore GI, a low cost and noninvasive procedure, can be recommended as an helpful tool in this type of surgery.

Adolescent↗

[Perineal regional anaesthesia: indications in gynaecologic and proctologic surgery and in obstetric].

Perineal and proctologic surgery is well known as very painful. The apparition of new specific needles, long acting and less toxic local anaesthetics and neurostimulation allowed reconsidering some old forgotten techniques. Those blocks appear really useful to optimize multimodal postoperative analgesia and postoperative rehabilitation. After anatomic review, authors describe perineal regional anaesthesia and discuss about main indications and advantages, in the eyes of their experience and bibliographic review.

Anesthesia, Conduction↗

[Current utility of endoanal ultrasound in the diagnosis of benign proctological disease].

Endoanal ultrasound is undoubtedly one of the major advances that has taken place in the evaluation of anorectal disease and pelvic floor disorders in the last decade. The main indications for endoanal ultrasound are evaluation of the morphology of the sphincteric apparatus in patients with fecal incontinence, the localization of perianal abscesses and fistulas, the staging of anal cancer and follow-up of squamous cell carcinoma after conservative treatment, and the study and morphological confirmation of lateral internal sphincterotomy in patients with fissure-in-ano, amongst others. In this article we review the main indications and use of endoanal ultrasound in the diagnosis of benign proctological disease.

Anal Canal↗

[Advisability of combined operations in proctologic patients].

The analysis of surgical treatment for combined diseases of the anorectal region in 106 patients is presented. The mean duration of the hospital stay after one-stage procedures made up 10.8 days, whereas in proctological patients with a single disease it made up 9 days. The individual approach to the choice of surgical policy and keeping to the order of the stages of the operation are essential in treatment of patients with combined diseases. The results of the study support the use of combined operations in patients with disease of the colon and the anorectal area.

Adult↗

[Ambulatory surgical interventions in patients with proctological diseases].

The results of 629 operations for the most frequent proctological diseases (hemorrhoid, anal scissure, rectal fistula, acute paraproctitis) were analyzed. 134 operations were performed in outpatient clinic, 225--in one-day hospital and 270 (control group)--in coloproctology department. The place of operation did not influence postoperative period and temporary disability time. The mean stay of patient in outpatient department and hospital surgical unit was 3.8 and 324 hours, respectively. Since the second day after operation in specialized department it is possible to perform therapeutic manipulations outpatient in coloproctology room without negative sequences for patient's health. Cost of the ambulatory operation constituted 28.4% of hospital stay for patients with similar interventions. Surgical treatment of the above diseases could be performed in outpatients setfing in more than 50% patients. The bed resources must be used for patients who need long-term and intensive treatment in specialized department.

Ambulatory Surgical Procedures↗

[Proctologic day-surgery. Results of 2000 surgical interventions].

The aim of the study was the evaluate of results of 2000 surgical operations for ano-rectal disease performed in the day-surgery setting (7-24 hours hospital stay) with improvement of both cost effectiveness and patient comfort. From January 1980 to December 1998, 2000 patients underwent surgical operations: 1011 for haemorrhoids; 708 for anal fissure; 172 for fistula in ano; 80 for pylonidal disease; and 45 for anal stenosis. 97.6% of patients were operated on with loco-regional anaesthesia; the others with narcosis and peripheral anaesthesia. The hospital-stay was 24 hours in 697 patients (34.5%), while 1319 (65.5%) operated on under loco-regional anaesthesia were hospitalised for 7-10 hours. Three patients (0.2%) developed acute hemorrhage after hemorroidectomy during the immediate postoperative period. They underwent reintervention under general anaesthesia with a hospital stay of 7 days. Four patients (0.6%) with perianal abscess after internal sphincterotomy underwent incision 10 days after the operation. Two patients with perianal hematoma after sphincterotomy prolonged the hospital stay for three days. In 1048 patients (51.9%) clinical recovery was observed at first follow-up (7 days); 48% had recovered at the 2nd follow-up (14 days). In 1608 patients (98%) anatomical recovery was observed at the follow-up three months after surgery. Patient satisfaction 6 month after operation was high in 79%; good in 27%; low in 1%. These results seems confirm the feasibility of proctological day surgery in almost all patients, with both a considerably cost reduction and enhanced patient comfort and compliance.

Ambulatory Surgical Procedures↗

Anal duct carcinoma: report of case and a survey of the experience of the American Osteopathic College of Proctology.

Anal duct carcinoma, also known as anal gland carcinoma or adenocarcinoma of the anal canal, is an unusual anal cancer that accounts for approximately 0.1% of all gastrointestinal cancers. Delays in diagnosis most likely account for the poor prognosis associated with this cancer. Presenting symptoms often mimic those of more common benign anorectal pathologic processes. Multimodality treatment that includes surgery, chemotherapy, and radiation therapy is often recommended. The authors describe a typical case of anal duct carcinoma and its management. They also discuss the findings of a survey of the combined experience of members of the American Osteopathic College of Proctology and review the literature.

Adenocarcinoma↗

[Use of mechanical staplers for the solution of proctological problems. Our experience with 122 patients].

The Longo technique using a circular stapler has changed haemorrhoid therapy. Thanks to the advent of this technique for treating haemorrhoids without excision, we can now successfully eliminate the mechanism responsible for their pathogenesis. The aims of circumferential stapled anoplasty are to correct the anodermal prolapse and restore the haemorrhoidal cushions to their anatomical position. Furthermore, with a few variants the technique can be utilised for other proctological problems, such as obstructed defecation in rectocele and incomplete internal prolapse (or rectal intussusception). The authors report on their experience in a consecutive series of 122 cases undergoing circular stapled anoplasty for haemorrhoids, associated in 10 cases with rectocele or rectal intussuscep-tion, analysing early and late complications after an accurate follow-up. The procedure can be performed with local or spinal anaesthesia. The operation lasted on average 19 minutes. There were few complications: early bleeding (4.9%), late bleeding (0.8%), mild stricture (2.5%) and thrombosis of external piles (8.2%). This new surgical technique is effective and rapid, causes only minimal postoperative pain and could be proposed as an alternative to traditional surgery also in the day surgery setting.

Adult↗

Proctologic disorders in sex deviates; a study of sixty-eight cases of sodomy.

Sixty-eight patients, 50 of them in penal institutions, who practiced passive sodomy were studied by interview and examination with regard to type of homosexuality, appearance, age at onset, frequency of practice, techniques, and proctologic findings.A high incidence of anal cryptitis was observed. A sign observable on digital examination, possibly peculiarly indicative of the practice of sodomy, was noted in many cases. Particular care is needed in the examination and treatment of anorectal diseases in sodomists and certain precautions must be taken as to hospital accommodations.

Anal Canal↗

[Ambulatory proctologic surgery].

An increasing number of proctological procedures may be performed on outpatients under extensive local anesthesia or by posterior perineal bloc. Precise selection criteria should be observed. Results of 1233 outpatients procedures are reported.

Adolescent↗

[Proctologic surgery in ambulatory care].

The principles for operations in the outpatient department are similar for proctology and general surgery. The trained and experienced surgeon is able to perform operations above the pectinate line, for example, polyps, prolapsing tumors etc. without stretching the anal sphincters and without anaesthesia being necessary. Below the dentate line local anaesthesia is sufficient for operative treatment of the following diseases: perianal thromboses, tumors of the skin and the connective tissue, skin tags, second degree hemorrhoids, segmental anal prolapses, anal fissures, cryptitis, uncomplicated anal fistulas and perianal abscesses. The postoperative treatment follows the rules of healing by second intention.

Ambulatory Surgical Procedures↗

[Ambulatory proctologic surgery].

Outpatient surgical proctology is nowadays more and more frequently performed. Between 1986 and 1989, 65% of 1149 anal surgical procedures were performed in our institution on an outpatient basis. The various criteria used to select patients fit for ambulatory surgery seemed adequate, as no complications were observed and no patient required secondary hospitalization.

Ambulatory Surgical Procedures↗

[A study on the use of ginkor in proctology (author's transl)].

A total of 37 ambulatory patients with proctological conditions were treated with Ginkor as preparatory therapy before instrumental treatment (sclerosants or elastic ligatures). Greater importance was attached to its hemostatic activity; always objective though sometimes transitory, than to the improvement in various painful functional syndromes. Changes in hemorrhoidal morphology were not included in the assessment, as they demonstrate very little in the course of general treatment, except in bouts of acute inflammation and more particularly when oedema and thrombis occur. After treatment, the functional syndrome (heaviness, tenesmus) which was present in 29 patients was absent in 9 cases, reduced in 13, and unchanged in 7. Pruritus ani, which was present in 14 patients, was absent in 4 cases, reduced in 5, unchanged in 4, and impossible to evaluate in 1 case. Rectorrhagia disappeared in 12 out of 20 cases, was reduced in 4 cases, and persisted in 4 others. Overall, there were 12 very satisfactory results, 13 incomplete results, 3 moderate results, and 9 cases where no effect was noted.

Adult↗

[Comparison of current proctological diagnostic studies].

The proctological investigation is explained, and the importance of the digital examination is stressed. Modern techniques do not alter the traditional examination but give more information on specific questions. Endosonography, computed tomography and magnetic resonance imaging help a great deal in tumor investigation. Endosonography is especially helpful in the definition of tumor extension, judgement of the anastomosis and rectal wall and lymph node involvement. Computer tomography permits to detect infiltration in the bone, and magnetic resonance imaging a precise tumor extension because of the multiplanar image. The distinction between recurrent tumor and postoperative fibrosis is possible by the latter and endosonography.

Anus Diseases↗

[Sacral anesthesia in proctology].

The experience with sacral anesthesia is reported on a total of 513 proctologic patients. From them, 105 cases were submitted to the sacral anesthesia without extradural morphine application, and 308 cases were anesthesized with simultaneous extradural administration of morphine. Easy in applicability, the sacral anesthesia is such an analgesic procedure which results in no complications and may be employed mainly in elder patients. The anesthetics prolonged in action (those similar in type with Bupivacain, Marcain) together with extradural morphine administration are also effective in respect with postoperative analgesia. An average time of postoperative analgesia represents 53 +/- 23.4 hrs. when 2 mg/kg Bupivacain, 0005% Epinephrine and 5 mg Morphinum hydrochloricum are applied, respectively.

Adult↗

[Ozone-oxygen therapy in proctology].

The diffusion of oxygen through the colon wall could be demonstrated in animal experiment. The relevant rise in PaO2 can be evidenced both in blood vessels and in the liver, whereby a significantly high increase of 250% above the normal value was recorded in the region of the intestinal wall. The venous blood values were at 230%, those in the portal vein at 134%, and in the liver parenchyma at 127%. When ozone is applied, these values are even higher. An increase can also be recorded in humans by means of transcutaneous PaO2 measurements. In proctology, we view the indication of rectal insufflation to be valid for colitis. The present report covers initial results and experience: a further short report on the possibility of treating hepatitis in the same way will be following.

Adult↗

[The symptomatic therapy of hemorrhoids and anal eczema--a report of experiences from proctology practice].

Besides the various operative procedures, which nowadays have come into use in hemorrhoidal disorders, drug therapy as well continues to keep an important place. Its main conditions of application are inflammatory processes before, between and after hemorrhoidal sclerosis or proctological operations. In a clinical study suppositories with the corticoid fluocortolone-21-pivalate and the local anesthetic lidocaine hydrochloride as well as a cream with the same substances and in addition, chlorquinaldol were tested in 92 patients with hemorrhoidal diseases and their concomitant conditions. In 92% of the cases efficacy of the preparations proved to be good or very good, and in all cases they were well tolerated.

Administration, Topical↗