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PubMed2000

[Contribution of ambulatory digestive surgery].

In France, ambulatory surgery is controlled by specific regulations which outline the organization of the facilities. It is practiced less in France than in other countries, but specific governmental incentive policies have been instituted. The characteristic feature of digestive surgery is the high occurrence of post-operative nausea and vomiting due to the peritoneal incision. New surgical procedures and anesthetic regimens allow ambulatory care in children and adults. But the choice of ambulatory care is based on the patient's characteristics more than on surgical procedure and follows well-known selection criteria. The procedures concerned in general surgery are groin hernia repair, proctologic surgery, and subcutaneous tissue surgery. Laparoscopic cholecystectomy and neck surgery in increasing numbers of patients on an ambulatory basis is the first step before expanding ambulatory surgical procedures toward major surgery. Physicians must have a thorough knowledge of ambulatory surgery as an organizational concept.

Adolescent↗
PubMed2000

[Diagnosis and therapy of anorectal diseases (excluding constipation and venereal diseases)].

In the last couple of years, the anorectum has been of great interest to gastroenterologists. With new diagnostic tools and a refinement of technique, together with new therapeutic modalities, interesting research results have been obtained. These results may be beneficial to patients therapy. The patients history, inspection and palpation of the anorectum remain the basic, essential features of diagnosis. Based on the symptoms and possible differential diagnosis, further investigation is necessary: Anorectal physiology and anal endosonography are also regarded as essential investigative techniques in a colorectal laboratory. Great progress has been made in the medical treatment in proctology in two areas: Biofeedback techniques and botulinum toxin injection. In the following article, definitions, symptoms, diagnosis and therapeutic modalities of common anorectal disorders are described.

Anus Diseases↗
PubMed2000

[Propofol and remifentanil in day surgery].

BACKGROUND AIM OF THE STUDY: to compare AG versus MAC using propofol & remifentanil in a day surgery setting evaluating intra and postoperative clinical conditions and emergence times. METHODS: Propofol and remifentanil, either for general anesthesia (AG) then conscious sedation (MAC), have been administered to 218 patients undergoing mainly plastic or proctologic surgery as day hospital. AG was induced with propofol 1.5-2 mg/kg followed by a continuous infusion of 10 mg/kg/h and remifentanil infused at 10 micrograms/kg/h; MAC was started with propofol 3 mg/kg/h and remifentanil 4-5 micrograms/kg/h; during the maintenance phase of both AG and MAC, infusion rates of both drugs were adjusted according to clinical needs. Diazepam (0.05-0.06 mg/kg) and/or midazolam (2-3 mg) were given as premedication or coinduction as necessary. All patients received field infiltration with local anesthetics (lidocaine or mepivacaine); patients under GA were artificially ventilated with O2/air through IOT or LMA. Surgical and anesthesiological data were collected on specially designed records, with special attention to time intervals between anesthesia (FA) and surgery (FC) end and eyes opening (EO), orientation (OR), return of spontaneous breathing (SR), extubation (EST), sitting (SED), walking (CAMM), dressing (VEST) and discharge (DIM); data were analyzed with parametric and non parametric analysis of variance. RESULTS: All emergence intervals were longer under AG than under MAC: the earlier in the range of 4-5 vs 0.5-1 min; for the late intervals; FA-SED 24 +/- 18 vs 15 +/- 8, FA-PIED 65 +/- 48 vs 34 +/- 17, FA-VEST 69 +/- 58 vs 33 +/- 17, FA-CAMM 68 +/- 42 vs 39 +/- 19. Discharge times (83 +/- 67 vs 73 +/- 60) were similar between the two groups. Drugs consumption under AG were roughly double than under MAC; total dose infused of propofol (mg/kg/min) 0.118 +/- 0.044 vs 0.06 +/- 0.036; total dose of remifentanil (microgram/kg/min): 0.106 +/- 0.049 vs 0.066 +/- 0.027. AG resulted in a higher % incidence of intraoperative hypotension and bradycardia: hypotension 61.7 vs 25.7 and bradycardia 30.3 vs 12.4. SaO2 decreased more commonly during MAC than AG (20.9% vs 10.1); intraoperative itching was referred in 20% of MAC patients. Conversions rate from MAC to AG was 2.8%. Psychomotor agitation was more frequent following AG (14%) than MAC (2%); nausea (1%), vomiting, shivering (12%), headache (2%), ortostatic hypotension (2%) were similar between the two groups. Diazepam and/or midazolam caused a significant prolongation of recovery intervals, for both AG and MAC with a mean delay of the order of 100-200%. CONCLUSIONS: Propofol- remifentanil gave excellent conditions for a wide variety of day surgery procedures, offering good anesthesia with quick emergence; the addition of bdz, even at low doses, prolongs significantly discharge times.

Adult↗
PubMed2001

[Lesions around the rectum. Diagnosing and treatment abscesses and fistulas].

Anorectal abscesses and fistulas are among the most common anorectal lesions. They represent different phases of one and the same condition, the abscess being the acute manifestation, the fistula the chronic form. In the event of a strong suspicion, rapid referral to hospital, preferably one specializing in proctology, is indicated. The treatment of choice of both abscesses and fistulas is surgery. Abscesses are widely incised and decompressed. Fistulas showing signs of fresh secretion may be treated initially by the insertion of a thread, and subsequently undergo definitive surgical treatment. The surgical procedure is determined by the site of the fistula. Attendant risks include recurrence and incontinence. When fistulas occur in Crohn's disease, the indication for surgical treatment must be stringently applied. In the absence of complications, postoperative healing of the wound should be checked regularly.

Abscess↗
PubMed2001

[Surgical treatment of hemorrhoid disease. A comparison between techniques].

BACKGROUND: The past years have seen the development of outpatient treatment and surgical procedures for the treatment of hemorrhoid disease in an attempt to reduce postoperative pain on the one hand and execution and hospitalisation times on the other. METHODS: This retrospective study compares the results obtained in the treatment of hemorrhoid disease using three different METHODS. Three groups of 30 patients were selected from those operated during the past 10 years using Milligan-Morgan s technique (Group A), Parks technique (Group B) and radiosurgery (Group C). All patients were matched for sex (50% males and 50% females), age (ranging between 30 and 50 years old), diagnosis (4th degree hemorrhoids not associated with another proctologic pathology such as anal fissures, fistulas, etc.) and referred symptoms. RESULTS: The results obtained allow a positive evaluation to be made of all three surgical techniques, but indicate submucous hemorrhoidectomy using radiosurgery as the method of choice for the treatment of grade III and IV hemorrhoids. CONCLUSIONS: The excellent results achieved using this approach in the authors opinion amply justify the relatively difficult execution and longer operating times.

Adult↗
PubMed2001

[Errors and complications in the treatment of hemorrhoids].

Long-term results of 724 hemorrhoidectomies were followed up from 6 months till 7 years. Various complications after operation were revealed in 172 (23.3%) patients. In 46 (26.7%) patients the failures were associated with unrecognized proctological diseases before operation, in 51 (30%)--with removal of hemorrhoids and in 63 (36.6%) patients the concomitant diseases of other organs and systems were the causes of complications.

Digestive System Diseases↗
PubMed1979

[A controlled study on the significance of occult blood test in the stool (author's transl)].

1000 patients of a proctological practice were all investigated by coloscopy and parallel to this by comparison of the two tests for occult blood in the stool (Haemoccult and hemo FEC). 5,6% were positive by the Haemoccult test, 5,2% to hemo FEC. There was no significant difference between the two systems. In the entire study 13 carcinomata and 39 benign polyps of 5 mm diameter and more were found, 8 patients with carcinoma had a positive hemo FEC test, 7 had a positive Haemoccult test, i.e. 38% of carcinoma patients were not detected by the hemo FEC test and 46% in the Haemoccult test. Even in patients with somewhat larger polyps, the test for occult blood in the stool was negative in 56%. It is pointed out with reference to two separate patients that in individual cases of even advanced carcinoma of the large intestine no blood can be detected in the stool.

Adenocarcinoma↗
PubMed2001

[Infliximab therapy for Crohn's disease anoperineal lesions].

AIM OF THE STUDY: To retrospectively evaluate the efficacy, the duration of response, and the tolerance of Remicade in anoperineal Crohn's disease. METHODS: Fifty patients with severe symptomatic and refractory anoperineal Crohn's lesions (38 fistulae and 29 cavitating ulcers and superficial fissures) were treated with 3 intravenous infusions of Remicade (5 mg/kg) at weeks 0, 2 and 6. Efficacy was assessed using Allan's functional score and proctologic examination at 8 weeks (W8) and 24 weeks (W24) after the first infusion. RESULTS: At W8, a response was noted for 71% (27/38) of fistulae and 79% (23/29) of ulcers and fissures. Healing rates were 39% and 49%, respectively. Efficacy of Remicade at W8 did not vary according to sex, number and type of fistulae and other treatments. At W24, 58% (15/26) of patients with fistulae and 63% (10/16) of patients with ulcers or fissures had a response. The response rate at W24 was higher in patients having anoperineal Crohn's lesions for less than one year: 77% vs 32% (P=0.004). Median Allan's score significantly decreased from 3.9 before treatment to 1.7 at W2 (P<0.001), 1.3 at W6 and 0.8 at W8. Median duration of response was 9.5 months (range: 0.5-12.5) after last infusion and was not influenced by associated treatments including immunomodulators. The relapse rate at 1 year was 64% for the responders followed at least one year (n=21). Minor adverse events occurred during 12% of all infusions. Eight patients had an infection, including one pneumonia. Eight patients developed a perineal abscess 16 weeks (range: 4-32) after the first infusion. CONCLUSION: Remicade is rapidly effective and well tolerated in anoperineal Crohn's lesions, but the high relapse rate stresses the need for long term therapeutic strategies in these patients.

Abscess↗
PubMed2002

[Anesthesiologic aspects of ambulatory surgery].

Experience of 2841 anesthesias during surgery performed in one-day hospital was analyzed. Anesthesiology service of the outpatient clinic consists of anesthesiologist, nurse-anesthesist, nurse of postoperative ward. Multicomponent anesthesia with tracheal intubation and artificial ventilation (386), combined (709), intravenous (511), inhalation (264), complex (473), neuroleptanalgesia (119), epidural (11), spinal (4), sacral (3), conduction (53) anesthesias were used during general, proctology, urology, oncology and gynecology surgeries.

Ambulatory Surgical Procedures↗
PubMedDate not supplied

[Development of surgical antibioprophylaxis kits: evaluation of the impact on prescribing habits].

In our hospital, surgical antibioprophylaxis (ATBP) was too often administered too late, thus raising the infectious risk. Antibiotic stocks of the anaesthesia department were also systematically used, instead of nominal prescriptions of these drugs. The pharmacy could neither charge antibiotics to each surgical department nor quantify and differentiate ATBP from curative antibiotic therapy. The pharmacy and anaesthesia departments therefore set out to standardize surgical ATBP, in order to adapt this treatment to each surgical indication, and particularly in the case of allergy to beta-lactamase antibiotics (second line treatment kits). Consequently, prescription forms were developed and supplied to each surgery department, as well as ATBP kits. The kits were prepared and distributed by the pharmacy, and comprised boxes containing antibiotics in sufficient quantities to respect the protocols approved by the French Society of Anaesthesia and Resuscitation (SFAR). A protocol describing prescriptions, dispensation and administration has been presented to physicians and nurses. Fifteen surgical departments were included in our study and 30 different kits were prepared. From 1998 to 2001, 5586 surgical operations required administration of a kit (second line treatment kits in 5% of cases): 1848 (33%) in visceral surgery; 764 (13.8%) in urology; 802 (14%) in orthopaedics; 13 (0.2%) in vascular and thoracic surgery; 1236 (22%) in ear-nose-throat (ENT), periodontics and ophtalmology, and 923 (17%) in gynaecology and obstetrics. 93% of filled prescriptions forms were spontaneously returned to the pharmacy, the others were obtained during the renewal of kit stocks. The cost (over 4 years) of ATBP was quantified: 157,871 F for the 15 departments included, 26,123 F in visceral surgery, 13,520 F in urology, 73,741 F in orthopaedics, 569 F in vascular surgery, 39,720 F in ENT/ophthalmology/periodontics and 4,198 F in gynaecology and obstetrics. According to the Altemeier classification, 2226 class I, 3151 class II, and 209 class III surgical operations were performed. Since the kits have been brought into use, the committee for the protection against nosocomial infections (CLIN) has observed a reduction in the incidence of post-operative infections, according to the Altemeier classification: from 1.6% to 0.5% in class I, from 6.5% to 4.3% in class II, and from 11% to 8.5% in class III. The difference was statistically significant only for classes I (p < 0.01) and II (p < 0.001), and unchanged for class III (p = 0.3). No analysis was carried out for class IV (curative treatments). Both nurses and physicians have greatly appreciated the implementation of this organization. The advantage in terms of post-operative infections, administration exhaustiveness and stock management is obvious. The prescribed kits were systematically appropriate for the surgical interventions. In orthopaedics, cefamandole was used over 24 h (188 kits) in ligament plasty and osteotomy, or for 48 h (499 kits) in prosthetic surgery; 24 amoxicillin/clavulanic acid (first line) and 9 clindamycin/gentamicin (second line) single dose kits have been prescribed in traumatic indications. In ophthalmology, kits were only prescribed in endophtalmitis (24 ofloxacin/fosfomycin single amount kits), implant replacement or cornea graft (1076 ofloxacin 24 h kits) and cataract surgery in diabetic patients (12 ofloxacin single amount kits). In ENT and periodontics, 124 surgical operations required cefazolin single dose kits. In vascular surgery, 5 pefloxacin/gentamicin 48 h kits and 1 amoxicillin/clavulanic acid 48 h kit were used in contaminated limb amputation, 1 cefamandole 48 h kit in class I surgery and 1 vancomycin 24 h kit (betalactamase antibiotic allergy); in thoracic surgery, 1 cefamandole 24 h kit was used for a thoracic wound. In visceral surgery, 9 different kits have been used, depending on the opening (class II) or not (class I) of the digestive tract. 797 cefazolin (first line) and 68 clindamycin/gentamicin (second line) single dose kits were used in class I surgery, and 689 amoxicillin/clavulanic acid single dose (SD) kits in class II surgery. Specific protocols consisted of 18 ceftriaxone/metronidazole and 48 metronidazole/gentamicin SD kits in oesophagus surgery, 11 ceftriaxone and 17 gentamicin SD kits in biliary endoscopy, 137 metronidazole SD kits in proctology and 34 amoxicillin/gentamicin 6 h kits for prevention of endocarditis. In urology, 133 cefotaxime and 20 pefloxacin/gentamicin SD kits were precribed in renal lithiasis, 102 amoxicillin/clavulanic acid SD kits in cystectomy, 27 amoxicillin/gentamicin 6 h kits in endocarditis prevention and 58 cefamandole SD kits in all other indications. In gynaecology and obstetrics, 534 cefazoline and 19 clindamycin/gentamicin (second line) SD kits were used, and 370 doxycyclin SD kits were prescribed in pregnancy termination. Some departments (orthopaedics and visceral surgery) adapted the protocols to their needs, specifically with regard to treatment duration. However, these situations were quickly corrected. A constant follow-up and update of this system, associated with routine audits, should allow the maintenance and possibly the improvement of these results, hence shortening treatment duration.

Anti-Bacterial Agents↗
PubMed2002

[The surgical gastroenterology department].

The Department of Digestive Surgery was born in 1977. It is a part of the medical surgical unit of gastroenterology and hepatopancreatology. The various developed sectors concern hepatic surgery and liver transplantation (treatment of hepatic tumors and cirrhosis), pancreatic surgery and surgery of the biliary tract (treatment of benign and malignant pancreatic tumors, tumor of the biliary tract, chronic pancreatitis and biliary stones), surgery of morbid obesity (gastroplasty or gastric by-pass), surgery of the upper digestive tract (benign and malignant tumors of the oesophagus or the stomach, treatment of gastroesophageal reflux), surgery of the abdominal wall, colorectal surgery and surgery of the inflammatory bowel diseases (colorectal cancer, familial polyposis, Crohn's disease, ulcerative colitis), proctologic surgery and surgery of anorectal functional disorders, neonatal and paediatric surgery.

Belgium↗
PubMed2003

[Results of ligature of distal branches of the upper rectal artery in chronic hemorrhoid with the assistance of Doppler ultrasonography].

In October 2000 to February 2002 Doppler ultrasonography assisted suturing and ligation of hemorrhoidal arteries were performed in 102 patients with chronic hemorrhoids (57 men, 45 women, mean age 44 +/- 4.3 years). The mean duration of the disease was 10 +/- 4.6 years. Elimination of scarlet blood and hemorrhoidal prolapse without concomitant proctologic diseases were indications for surgery. Sixty-nine patients were followed up for more than 12 months, the follow-up lasted on the average 12 +/- 4 months. There were no clinical symptoms in 57 (82.6%) on the 69 patients. Combined ligation of arterial branches and nodes with latex rings was performed in 7 patients with stages III-IV hemorrhoids. Sclerotherapy was performed in 2 patients with stage III with occasional elimination of blood on defecation. Hemorrhoidectomy was performed in 3 (2.9%) patients with stage IV hemorrhoid due to ineffective ligation. Suturing and ligation of distal branches of the upper rectal artery decrease the inflow of arterial blood to hemorrhoidal nodes without venous outflow disorders. Fixation of hemorrhoidal nodes to the muscular wall eliminates the symptoms of hemorrhoidal prolapse. These factors lead to elimination of hemorrhoidal symptoms in 82.6% of the patients operated on.

Adult↗
PubMed1992

[Loop colostomy in patients with cancer of the colon and rectum].

At the clinic of Scientific Research Institute of Proctology, Ministry of Public Health of Armenia, in 97 patients with complicated cancer of the colon and rectum, a two-barrel loop colostomy was created for the recent 10 years. Use of intraperitoneal method contributed to 3-fold decrease in incidence of postoperative purulent complications. Irrigation of a tumour site with antibacterial preparations in perifocal inflammation of colonic cancer together with carrying out the complex antibacterial therapy permits to perform the radical operations.

Adult↗
PubMed2003

[Nerve sparing radical hysterectomy in the case of cervical cancer].

Autonomous pelvic nerves are essential for bladder and rectum function as well as sexuality. These nerves are usually permanent damaged during radical oncological surgery and this results in urological, sexual and proctological morbidity. Japanese surgeons have paved the way for surgical approaches to dissect these nerves during surgery and leave them intact. At the Department of Gynaecology of the Leiden University Medical Center, the Netherlands, a new surgical technique has been developed to spare the autonomous pelvic nerves during radical hysterectomy. In this procedure the lateral parts of the sacro-uterine ligament, through which the N. hypogastricus passes bilaterally, are left intact. The initial results of this nerve-sparing surgical technique during radical hysterectomy seem to be promising. The operation was easy to perform, with almost no extra blood loss and an extra operating time of just 10-15 minutes. Postoperative recovery of the bladder function occurred after a mean period of 9 days.

Female↗
PubMed2003

[Milligan-Morgan hemorrhoidectomy with a radiofrequency scalpel].

BACKGROUND: Postoperative pain has always been the main adverse effect of surgical treatment for hemorrhoids. Therefore, surgical techniques evolved mainly to solve this problem and, secondly, postoperative bleeding, recurrences and stenosis. METHODS: Two homogeneous groups of 20 patients each were investigated. Both of them were affected by fourth grade hemorrhoidal prolapse and were homogeneous for age, sex and presentation symptoms. Patients previously treated for other proctologic diseases were excluded. A group was treated with standard Milligan-Morgan hemorrhoidectomy and the other with radiofrequency scissors. Every patient underwent a follow-up protocol based on outpatient visits at 15, 30, 45 postoperative days and 3, 6 and 12 months. RESULTS: The results show a substantial similarity between these techniques. However, radiofrequency scissors further improved the simplicity of the technique and the postoperative adverse effects. In particular, the procedure lasted 7 minutes less with radiofrequency scissors. Patients treated with the radiofrequency technique had their first postoperative evacuation 24 hours before the standard technique and reduced the mean postoperative hospital stay at 2.5 days (4.5 days in the standard group). The incidence of postoperative pain was reduced in patients treated with radiofrequency scalpel and the follow-up controls in both groups didn't show any complication as stenosis or incontinence. CONCLUSIONS: The radiofrequency-performed Milligan-Morgan hemorrhoidectomy is a valuable technique that improves the classical difficulties in execution, reducing the length of hospital stay and the incidence of postoperative pain or other complications.

Adult↗
PubMed1992

[Rational neurologic diagnosis in fecal incontinence].

The effective therapy of a disturbance of anal continence requires an adequate preoperative diagnostics. In most cases this includes some kind of neurophysiological investigation. Close cooperation between the internist, the surgeon and the neurologist is advantageous. The initial history, clinical examination and electromyography of the pelvic floor will usually be enough to differentiate between aetiologies. In the first phase it is necessary to decide whether the problem is neurogenic or muscular, and then to see localising signs for a nerve defect (central or peripheral) or, respectively, signs of a defect in the skeletal musculature. It must be said that a peripheral nerve lesion (eg. a stretching injury of branches of the pudendal nerve) and a muscular defect may be combined. At the end of the diagnostic process the surgeon or internist and neurologist must decide together whether the diagnosis is appropriate, and then whether an operative or non-operative approach to treatment is fitting. In the second phase of diagnosis are further neurophysiological investigations, which are only indicated in more special circumstances. These investigations include: nerve conduction velocities, reflex latencies (anal-, bulbocavernosus-, and pudendoanal reflexes), evoked potentials, and the single fibre EMG to determine fibre density. These neurophysiological investigation in proctology allows the clinician a wider scope of diagnostic possibilities, which should lead to more sensible therapeutic options being taken.

Electromyography↗
PubMed1992

[The groups at risk for a recurrence of rectal cancer after radical operations].

The article discusses a group of patients with rectal carcinoma who underwent radical operations at the Scientific Research Institute of Proctology in 1982-1983. The terms and frequency of rectal carcinoma recurrences are analysed and the factors influencing these indices are studied. The results made it possible to form a group with a risk of a recurrence among patients with carcinoma of the rectum and suggest new schedules of regular medical observation over these patients with consideration for the risk group.

Adenocarcinoma↗
PubMed1992

[The use of diagnostic and therapeutic colonofibroscopy in children].

The results of investigation of the large intestine in 187 children were analysed. Of them, in 28 the terminal ileum was as well examined. In 38 patients with polyps and intestinal invagination, colonoscopy was performed in combination with endoscopy. Colonofibroscopy was used as a primary method of study to establish the causes of intestinal hemorrhage, colitis syndrome. The method has a high informative value, permits to extend the diagnostic and therapeutic possibilities in pediatric proctology.

Adolescent↗