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PubMed2002

New approaches to the treatment of anal fissure.

According to Antropoli, pathologies of the anal canal are extremely common. About 30 to 40 percent of the population suffers from proctologic pathologies at least once in their lives. In most cases they are more annoying than dangerous. Anal fissure (AF) was recognized as a clinical entity in 1934. It is a longitudinal defect of the anal canal mucosa and anoderm extending usually from the dentate line to the external verge of the anal canal. This defect exposes the lower half or even most of the fibres of internal anal sphincter. AF is almost always accompanied by extensive tension of this muscle. Anal fissures affect all age groups but predominantly occur in the 3rd and 4th decades of life (2, 8, 23). Gathright states that fissure disease causes from 6 to 15% of office visits and 10% of operative procedures in a colorectal practice. The etiology of anal fissure has only been partially explained and remains controversial although spasm of the internal anal sphincter has been recognized to play a main role in the pathogenesis of this disease. Recent studies have cast new light on the pathogenesis of anal fissures.

Fissure in Ano↗
PubMed2006

Radiofrequency surgery--novel techniques in the treatment of ano-rectal disease.

BACKGROUND: Radiofrequency surgery is a method of utilizing high frequency (3.8 to 4MHz) radio wave energy to incise, excise, or coagulate tissues. Radiofrequency (RF) is a relatively new modality that is being used for ano-rectal surgeries with increasing frequency. As the RF energy is applied, frictional heating of tissues results, with cell death occurring at temperatures between 60 and 100 degrees C. OBJECTIVE: This paper discusses author's clinical experience with radiofrequency for various ano-rectal pathologies namely hemorrhoids, anal fistula, anal polyps, sinuses and anal papillae. A Ellman dual frequency radiofrequency generator was used to carry out the procedures. This study is intended to be somewhat of a "how we do it" manual, explaining the principles of radiofrequency. CONCLUSION: Radiofrequency proctological procedures are simple to perform with many advantages over the more traditional techniques. The procedures take less operative time, the postoperative recovery is accelerated and the incidences of complications are negligible.

Anus Diseases↗
PubMed2004

Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery?

AIM: Hypertrophied anal papillae and fibrous anal polyps are not given due importance in the proctology practice. They are mostly ignored being considered as normal structures. The present study was aimed to demonstrate that hypertrophied anal papillae and fibrous anal polyps could cause symptoms to the patients and that they should be removed in treatment of patients with chronic fissure in anus. METHODS: Two groups of patients were studied. A hundred patients were studied in group A in which the associated fibrous polyp or papillae were removed by radio frequency surgical device after a lateral subcutaneous sphincterotomy for relieving the sphincter spasm. Another group of a hundred patients who also had papillae or fibrous polyps, were treated by lateral sphincterotomy alone. They were followed up for one year. RESULTS: Eighty-nine percent patients from group A expressed their satisfaction with the treatment in comparison to only 64% from group B who underwent sphincterotomy alone with the papillae or anal polyps left untreated. Group A patients showed a marked reduction with regard to pain and irritation during defecation (P = 0.0011), pricking or foreign body sensation in the anus (P = 0.0006) and pruritus or wetness around the anal verge (P = 0.0008). CONCLUSION: Hypertrophied anal papillae and fibrous anal polyps should be removed during treatment of chronic anal fissure. This would add to effectiveness and completeness of the procedure.

Adult↗
PubMed2005

Sequential treatment for proctalgia fugax. Mid-term follow-up.

INTRODUCTION: Proctalgia fugax (PF) is a benign, self-limiting disease characterized by episodes of intense anorectal pain at frequent intervals in the absence of organic proctological disease. Even though PF was described more than a century ago, its etiology remains unclear. Currently there is no information available. Few papers quoting many ways of management have been published. The aim of this study was to investigate patients complaining of this condition and to treat them with sequential therapy. PATIENTS AND METHODS: We devised a descriptive, prospective study of patients complaining of acute perianal pain--duration less than 30 minutes--without organic disease or previous perianal surgery since 1996 to 2002 in our Department. We treated these patients using a three-step treatment (1: information, hip bath, benzodiazepines; 2: sublingual nifedipine 10 mg, or topic 0.1% nitroglycerin on demand; 3: internal anal sphincterotomy if hypertrophy of the internal anal sphincter was demonstrated by anal ultrasonography and no improvement was confirmed with the previous steps of treatment). We defined remarkable improvement as a decrease in the number of episodes by half or in pain intensity by 50%. RESULTS: Fifteen patients with an average follow-up of 4 years. Anal endosonography confirmed a grossly thickened internal anal sphincter (IAS) in 5 cases. After the first step of treatment 7 patients improved and 1 patient was cured; after the second step of treatment 3 patients improved and 1 was cured; the third step was applied to 3 patients with a thickened IAS; 1 patient improved and 1 patient was cured. CONCLUSION: A total resolution of PF is not always possible, but we may improve symptoms and their frequency. Almost 50% of patients in our series improved with the first step of treatment; 30% of our patients had IAS hypertrophy. Anal endosonography can help in the diagnosis of organic diseases or IAS hypertrophy, for which we can perform an internal anal sphincter myectomy.

Acute Disease↗
PubMed1980

Sexually transmitted diseases and traumatic problems in homosexual men.

In addition to gonorrhea and syphilis, both of which may develop primarily at anorectal or pharyngeal sites, a number of conditions, including Neisseria meningitidis urethritis, nonspecific urethritis, anorectal herpes, condyloma acuminatum, amebiasis, giardiasis, shigellosis, typhoid fever, enterobiasis, and hepatitis A and B, have been identified as being transmitted by male homosexual contact. Proctologic complications of anal intercourse include allergic reactions to anal lubricants, prolapsed hemorrhoids, and fistulas, and fissures. Rectosigmoid tears may result from fist, forearm, and foreign body penetration of the bowel. Physicians can best help their homosexual patients by accepting them and their relationships nonjudgmentally and by understanding their special health needs.

Genital Diseases, Male↗
PubMedDate not supplied

[Utilization of medical resources for patients with irritable bowel syndrome in a tertiary hospital].

BACKGROUND: The irritable bowel syndrome (IBS) produces a high cost to society in terms of work loss, consultations, medical tests, treatments and even unnecessary surgeries. AIMS: To evaluate the use of medical resources by IBS patients in a tertiary hospital. METHODS: Retrospective study of medical records from patients with IBS younger than 60 years old. Number of clinical studies, consultations to all specialties and number of surgeries were analyzed. RESULTS: Between 1987 and 1996, 98 patients age (mean) 40.8 years, were identified. Follow-up time was 33.4 months (1-243), during a mean of 22.4 studies per patient (1-82) were solicited. Prior to IBS diagnosis, 5.0 studies per patient (I-II) were required. In 87% of the cases, IBS diagnosis was established during the first visit. Each patient consulted 3.6 times/year, 44.2% for gastrointestinal symptoms and 48.6% for non-gastrointestinal symptoms. The consultations with the most demand were internal medicine (53.0%), gastroenterology (38.8%), proctology (31.6%), psychiatry (21.4%), gynecology (18.4%) and urology (13.3%). Surgical history was found in 39%, 17.3% had appendectomy and 13.3% cholecystectomy, 1.02% and 2.04% respectively were done after IBS diagnosis. CONCLUSIONS: Although the availability of the Rome criteria for the diagnosis of IBS, these patients require an excessive quantity of studies to eliminate the possibility of organic disease, and excessive number of annual medical consultations as well. IBS patients also have a high rate of appendectomies and cholecystectomies.

Adolescent↗
PubMed1998

Comparative evaluation of the complex treatment of rectal cancer patients (chemotherapy and X-ray therapy, Ukrain monotherapy).

A total of 48 patients suffering from rectum cancer were included in this randomized study conducted at the Proctology Department of the Donetsk Regional Anti-Cancer Center. Patients in group I (24 patients) received an intensive course of high fractional X-ray therapy (cumulative dose up to 25 Gy) with direct protracted endolymphatic chemotherapy with 5-fluorouracil (5-FU) instilled in 600 mg/m2 each day before operation, up to a cumulative dose of 5 g. The 24 patients in group II were treated with Ukrain as monotherapy, 10 mg each second day before operation (up to a cumulative dose of 60 mg) and a total of 40 mg after surgical intervention. Repeated Ukrain courses (100 mg/per course) were also given 6 months after surgical operation. In each ease preoperative treatment was followed by routine surgical operation. Prolongation morbi were found to have developed 14 months later in six patients in group I (25.0%), whereas in group II they were found only in two cases (8.3%). Comparative investigation of objective and subjective signs, analysis of results of instrument and X-ray data, as well as dynamic study of the histological structure of rectal tumors, indicate that Ukrain exerts a more potent malignotoxic and immunomodulating action than other types of anticancer treatment.

Adult↗
PubMed1976

[Treatment of internal hemorrhoids by the method of nonsurgical ligature combined with proctoglivenol].

In the Research Laboratory of Proctology with the clinic of the RSFSR Ministry of Health since 1974 a nonoperative ligature method was employed for treatment of 50 patients at high risk for this affection. A combined use of the nonoperative method and proctoglivenol suppositories is a rather effective therapeutic measure, which is indicated for treatment of hemorrhoids in patients, in whom operative intervention is contraindicated.

Age Factors↗
PubMedDate not supplied

[Our experience in internal medioposterior sphincterotomy with anoplasty].

BACKGROUND: The technique of the posterior medial internal sphincterotomy according to Arnous is described and advice from personal experience reported. METHODS: From 1981 to 1995 posterior medial internal sphincterotomy with anoplasty was performed in 270 patients (132 males and 138 females) affected with chronic anal fissure, alone (112 cases) or associated with hemorrhoids (80 cases); moreover, the Arnous's operation was performed as well for hemorrhoids with posterior subsidiary packet and internal sphincter hypertonia (52 cases), relapsed hemorrhoids with postoperative anal stenosis (24 cases) and postoperative anal stenosis with painful fissure and residual internal sphincter hypertonia (2 cases). RESULTS: The results have been excellent; the average stay in hospital has been 7 days and the complete recovery occurred after 4-6 weeks without early or late complications. CONCLUSIONS: The importance of anorectal manometry for the preoperative valuation of the sphincteric hypertonia is emphasized: in this manner it is possible to modulate the sphincterotomy avoiding too economic sphincteric sections with next residue hypertonia or, in the contrary, too plentiful sphincteric section with problems of continence. Finally, the internal lateral-left sphincterotomy is mentioned, which is efficacious in the treatment of acute anal fissure. However, the proctological surgeon, on the basis of his experience, will propose the most convenient technique.

Adult↗
PubMedDate not supplied

[Defecography and treatment of essential anal pain].

INTRODUCTION: Proctalgia is a chronic anal pain in the absence of any organic conditions of the anorectum and excluding such morphofunctional disorders as rectal prolapse, intussusception and solitary rectal ulcer, which are easily shown with defecography but not with other imaging techniques. Proctalgia patients undergo a long workup and many instrumental and radiologic examinations and are finally referred to the proctologist with a condition which is difficult to diagnose and treat. We investigated the defecographic findings and anorectal abnormalities of essential proctalgia, as well as the correlation between radiologic findings, clinical symptoms and efficacy of biofeedback treatment. MATERIALS AND METHODS: We retrospectively examined 31 patients (21 women and 10 men; age range: 25-67 years, mean: 46) with defecography, clinico-proctologic investigations integrated with anoscopy and sigmoidoscopy, anorectal manometry and psychological tests. The women were submitted to gynecologic examination: 8 patients had a history of anorectal and pelvic surgery. We did not perform anal electromyography because it may cause painful sphincterial spasms. All patients underwent 30-minute weekly sessions of biofeedback till regression of symptoms. RESULTS: Anal pain was described as anorectal in 18 cases, anoperineal in 7, anosphincterial in 5 and rectovaginal in 1 case. It radiated to the sacrum in 42% of cases, thighs in 23%, gluteus muscles in 19%, and was related to evacuation in 39% of cases. Pain lasted some hours (58%) to a few minutes (42%). Manometric data showed sphincterial hypertonia in 14 patients. Eleven patients suffered from anxiety and were on drug treatment. Defecography demonstrated rectocele in 15 cases, puborectalis muscle syndrome in 14, external sphincter spasm in 12, perineal descent in 8, rectal muscosal prolapse in 4, intussusception in 3 and fecal incontinence in 2 cases. After 10 weeks of biofeedback training, all patients reported improvement of symptoms, which was confirmed at manometry as reduced sphincterial pressure. CONCLUSIONS: The etiology of essential proctalgia is unknown, but functional disorders of the pelvic floor and sphincterial muscles, as well as altered perineal stasis and pudendal conditions, all play an important role. These data are confirmed in our study where puborectalis syndrome, external sphincterial spasm and perineal descent are involved in over 70% of cases. Defecography is a useful tool because it permits to diagnose abnormal anorectal morphology and to diagnose sphincterial and puborectalis muscle dysfunctions which are missed with other instrumental and imaging techniques.

Adult↗
PubMed1999

Fissure-in-ano, to divide or not to divide?

Anal fissure is one of the most common and painful proctological pathologies affecting mainly young individuals. The physiopathology in the development of a chronic anal fissure seems to be a combination of internal anal sphincter hypertonia and poor vascularization at the posterior midline. Treatment of acute fissures is conservative with supportive therapy, leading to healing in the majority of the patients. Open or closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissures. In low pressure chronic fissures, sphincterotomy should be avoided and a V-Y island advancement flap may be an alternative procedure. Sphincterotomy can induce anal incontinence, a feared complication of this technique. Recent interest has developed in chemical sphincterotomy with local botulin toxin injections or glyceryl trinitrate application. Long-term follow-up is needed to evaluate these new therapeutic options.

Algorithms↗
PubMed1999

Pruritus ani.

The possible dermatological and proctologic causes, of Pruritus Ani that often, due to its persistence and for its consequent lesions of scratching, becomes a real disease, are analysed. Particular attention is given to therapeutical treatment, describing which hygienic-dietetic rules must be followed and which treatments can be utilised, if the cause of the symptom is known and if it is possible to remove it or not. Moreover, personal experience on 312 patients examined in twelve years is reported.

Adult↗
PubMed1999

[Defecography by spiral computed tomography].

PURPOSE: We investigated the possible role of helical CT defecography in pelvic floor disorders by comparing our results with those of conventional defecography. MATERIAL AND METHODS: Our series consisted of 90 patients, namely 62 women and 28 men, ranging in age 24-82 years. They were all submitted to conventional defecography, and 18 questionable cases were also studied with helical CT defecography. The conventional examination was performed during the 4 standard phases of resting, squeezing, Valsalva and straining; we used a remote-control unit. The parameters for helical CT defecography were: 5 mm beam collimation, pitch 2, 120 KV, 250 mAs and 18-20 degrees gantry inclination to acquire coronal images of the pelvic floor. The rectal ampulla was distended with a bolus of 300 mL nonionic iodinated contrast agent (dilution: 3 g/cc). The patient wore a napkin and was seated on the table, except for those who could not hold the position and were thus examined supine. Twenty-second helical scans were performed at rest and during evacuation; multiplanar reconstructions were obtained especially on the sagittal plane for comparison with conventional defecographic images. RESULTS: An unquestionable diagnosis could be made in all the 18 patients submitted to helical CT defecography. The diagnosis was in agreement with proctology results and added new information in all cases. Sixteen patients had constipation and 2 fecal incontinence--one from rectal prolapse and the other from a rectovaginal fistula. In this latter case helical CT defecography permitted to confirm the fistula and suggest its course. One patient had a previously undetected ovarian cancer metastatic to the anterior rectal wall. DISCUSSION AND CONCLUSIONS: Coronal helical CT defecography images permitted to map the perineal floor muscles, while sagittal reconstructions provided information on the ampulla and the levator ani. To conclude, helical CT defecography performed well in the study of pelvic floor disorders and can follow conventional defecography especially in questionable cases.

Adult↗
PubMed1999

Laparoscopic colorectal procedures: a multicenter Brazilian experience.

An evaluation of the results of the Brazilian experience in colorectal laparoscopic procedures in a multicenter prospective protocol done by the Brazilian Society of Colo-Proctology is presented. From December 1991 to August 1998, 1,161 patients (583 men and 578 women; mean age, 49.8 years), were operated on laparoscopically. Most of the procedures (40.5%) were for cancer, and the most common procedure was anterior resection (22.5%). The mean operative time was 189 minutes (3.1 hours). There were 42 (3.6%) perioperative complications; visceral injuries were the most common (1.4%). Conversions occurred in 122 (10.5%) cases. There were 148 (12.7%) postoperative complications; wound infections were the most common (5.2%). A liquid diet was started at a mean time of 1.4 days after the operation, and the mean hospitalization period was 6.4 days.

Adult↗
PubMed2000

[Treatment of patients with foreign bodies in rectum].

The analysis of treatment results in 112 patients with foreign bodies in the rectum, aged from 16 to 80 years, was carried out. 99.1% of the patients were men. All the patients were examined and treated in proctology department of the Moscow municipal clinical hospital N 67 from 1969 to 1998. The examination was made by standard scheme, including rectal touch, rectoromanoscopy, X-ray and ultrasonic examinations. In 107 patients the foreign body was removed without surgery, 5 patients required laparotomy. When possible it was removed by fingers and also with use of forceps. When small foreign bodies could not be reached by finger, they were removed through rectoscope. Foreign bodies of big sizes, proximal end of which was in the sigmoid colon, were removed under anasthesia with the help of the assistant who fixed the foreign body through the abdominal wall in the left ileac region. In impossibility of the subject removal by these methods and presence of complications (perforation, peritonitis), laparotomy with subsequent transanal subject removal without colon section was performed, in case of perforation--with wound suturing or colostomy.

Adolescent↗
PubMed2000

[Most frequent causes of fecal incontinence in our environment].

The objective of this piece of work was to assess the most frequent causes of fecal incontinence in our environment. 204 patients undergoing fecal incontinence of various types of severity were evaluated and later referred to "motilidad digestiva" department of Gastroenterology floor of Hospital de Clínicas José de San Martín, in an eight year span of time, 58 male (28.43%) and 146 female (71.56%) of an average age of 56 years. Every patient underwent a serious anamnesis, a proctologic examination, anoscopy, a rectosigmoid study, an anorectal manometry, and, a preventive electromyography was performed to those patients with a possible neurologic damage. The most frequent cause of incontinence was idiopathic 37.7%, followed by post surgery (19.6%) and rectal prolapse (13.7%), post menopause (11.2%), post delivery (9.8%), Neurogenic Incontinence (4.9%) and Traumatic Incontinence (2.9%). Doctor's performance may prevent some of the causes of incontinence.

Aged↗
PubMed2000

[Analytical review of multicenter studies with polycresulene for hemorrhoidal pathologies].

Seven centres investigated the therapeutic efficacy and tolerability of policresulene associated to cinchocaine administered locally as ointment, suppositories or both formulations in 2287 patients with hemorrhoid pathology. The studies were conducted with a standardised protocol and case report forms and with the same score criteria for rating efficacy and tolerability according to the physicians and the patients. Highly satisfactory results were achieved in 1904 patients (83.2%) according to the investigators criteria. Patients rated the outcome most satisfactory for 1881 cases (82.2%). The following were found to be the principal indications: external and internal hemorrhoids associated with bleeding, acute anal fissures, rhagades and perforated or incised perianal thrombosis, anal eczema and anal pruritus, proctitis and wound treatment after proctologic surgery. None of the investigators found any serious adverse event. Mild to moderate adverse reactions in 10% of the patients were local discomfort, pruritus, burning or irritation. Such symptoms occurred at the beginning of treatment. The favourable effects of policresulene are attributed to its unique mechanism of action. The highly acid characteristics of the substance causes a selective coagulation of the necrotic tissues leaving healthy tissues unaffected. The desquamation and remotion of the necrotic tissues induces rapid wound cleansing, and a reactive hyperemia of the treated area enhancing epithelization. Its highly acid pH produces a marked bactericidal action on the most common pathogens and C. albicans as well. Policresulene has hemostyptic properties producing vasoconstriction of the myofibrils of the blood vessels arresting profuse bleeding from large areas. The local anesthetic cinchocaine contributes to the initial pain relief. None of the formulations contains corticosteroids which makes this preparations also suitable for long term treatment periods.

Anesthetics, Local↗
PubMed2000

Assessment of sphincterotomy results in patients treated for anal fissure.

OBJECTIVE: This paper summarizes results of a study of 90 patients operated on for chronic anal fissure with lateral sphincterotomy (LS) between 1985 and 1997. METHODS: Preoperative and postoperative complaints, anal examination and continence were evaluated. All patients were asked to rate the results of LS as very good, good, satisfactory or unsatisfactory. RESULTS: Sixty-six patients (73.3%) judged the results of LS to be very good. Only 4 (4.4%) judged the results unsatisfactory and 1 patient (1.1%) considered the results satisfactory. Recurrent anal fissure was found in 4 cases (4.4%). Two patients developed a fistula in connection with the procedure. CONCLUSIONS: Lateral sphincterotomy is a safe and simple operation that yields good results. However, LS should be diagnosed and performed by a surgeon skilled in proctologic surgery.

Chronic Disease↗