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The S2k guideline on hidradenitis suppurativa/acne inversa (HS/AI) aims to provide an accepted decision aid for the selection/implementation of appropriate/sufficient therapy. HS/AI is a chronic recurrent, inflammatory, potentially mutilating skin disease of the terminal hair follicle-glandular apparatus, with painful, inflammatory lesions in the apocrine gland-rich regions of the body. Its point prevalence in Germany is 0.3%, it is diagnosed with a delay of 10.0 ± 9.6 years. Abnormal differentiation of the keratinocytes of the hair follicle-gland apparatus and accompanying inflammation form the central pathogenetic basis. Primary HS/AI lesions are inflammatory nodules, abscesses and draining tunnels. Recurrences in the last 6 months with at least 2 lesions at the predilection sites point to HS/AI with a 97% accuracy. HS/AI patients suffer from a significant reduction in quality of life. For correct treatment decisions, classification and activity assessment should be done with a validated tool, such as the International Hidradenitis Suppurativa Severity Scoring System (IHS4). HS/AI is classified into two forms according to the degree of detectable inflammation: active, inflammatory (mild, moderate, and severe according to IHS4) and predominantly inactive, non-inflammatory (Hurley grade I, II and III) HS/AI. Oral tetracyclines or 5-day intravenous therapy with clindamycin are equal to the effectiveness of clindamycin/rifampicin. Subcutaneously administered adalimumab, secukinumab and bimekizumab are approved for the therapy of HS/AI. Various surgical procedures are available for the predominantly non-inflammatory disease form. Drug/surgical combinations are considered a holistic therapy method., (© 2024 Deutsche Dermatologische Gesellschaft (DDG).)

Background/aims: The aim of this study was to evaluate the sustainability of sacral neuromodulation (SNM) success in patients with fecal incontinence (FI) and/or constipation., Methods: This is a retrospective analysis of a prospective database of patients who received SNM therapy for FI and/or constipation between 2006 and 2015. Success rates, complications and reintervention rates were assessed after up to 10 years of follow-up., Results: Electrodes for test stimulation were implanted in 101 patients, of whom 79 (78.2%) received permanent stimulation. The mean follow-up was 4.4 ± 3.0 years. At the end of follow-up, 57 patients (72.2%) were still receiving SNM. The 5-year success rate for FI and isolated constipation was 88.2% (95% confidence interval [CI], 80.1-97.0%) and 31.2% (95% CI, 10.2-95.5%), respectively ( P ＜ 0.001). In patients with FI, involuntary evacuations per week decreased ＞ 50% in 76.1% of patients (95% CI, 67.6-86.2%) after 5 years. A lead position at S3 was associated with an improved outcome ( P = 0.04). Battery exchange was necessary in 23 patients (29.1%), with a median battery life of 6.2 years. Reinterventions due to complications were necessary in 24 patients (30.4%). For these patients, the 5-year success rate was 89.0% (95% CI, 75.3-100.0%) compared to 78.4% (95% CI, 67.2-91.4%) for patients without reintervention., Conclusions: SNM offers an effective sustainable treatment for FI. For constipation, lasting success of SNM is limited and is thus not recommended. Reinterventions are necessary but do not impede treatment success.

Background: Surgical wound classification (SWC) is used for risk stratification of surgical site infection (SSI) and serves as the basis for measuring quality of care. The objective was to examine the accuracy and reliability of SWC. This study was purposed to evaluate the discrepancies in SWC as assessed by three groups: surgeons, an infection control nurse, and histopathologic evaluation. The secondary aim was to compare the risk-stratified SSI rates using the different SWC methods for 30 d postoperatively., Methods: An analysis was performed of the appendectomies from January 2013 to June 2014 in the Cantonal Hospital of Schaffhausen. SWC was assigned by the operating surgeon at the end of the procedure and retrospectively reviewed by a Swissnoso-trained infection control nurse after reading the operative and pathology report. The level of agreement among the three different SWC assessment groups was determined using kappa statistic. SSI rates were analyzed using a chi-square test., Results: In 246 evaluated cases, the kappa scores for interrater reliability among the SWC assessments across the three groups ranged from 0.05 to 0.2 signifying slight agreement between the groups. SSIs were more frequently associated with trained infection control nurse-assigned SWC than with surgeons based SWC., Conclusions: Our study demonstrated a considerable discordance in the SWC assessments performed by the three groups. Unfortunately, the currently practiced SWC system suffers from ambiguity in definition and/or implementation of these definitions is not clearly stated. This lack of reliability is problematic and may lead to inappropriate comparisons within and between hospitals and surgeons., (Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Hemorrhoidal disease represents a prevalent benign condition of the lower gastrointestinal tract. As a common and early symptom of hemorrhoids, patients present with painless rectal bleeding during or after defecation. For the treatment of hemorrhoidal disease, a large variety of operative and non-operative therapeutic options exists. In the present article, the authors aim to provide guidance for stage-directed therapy of hemorrhoidal disease based on up-to-date knowledge and the authors' own clinical experience.

Background: Stapled transanal rectal resection with a new, curved, multifire stapler (Transtar procedure) has shown promising short- and midterm results for treating obstructed defecation syndrome. However, few results have been published on long-term outcome., Objective: This study aimed to investigate long-term functional results and quality of life after the Transtar procedure., Design: This is a retrospective study., Setting: This study was conducted at a tertiary hospital in Switzerland., Patients: Seventy consecutive patients (68 female) with obstructed defecation syndrome had a median age of 65 years (range, 20-90)., Intervention: The Transtar procedure was performed between January 2007 and March 2010., Main Outcome Measures: Postoperative functional results were evaluated with the Symptom Severity Score, Obstructed Defecation Score, and Cleveland Incontinence Score. Quality of life was evaluated with the Fecal Incontinence Quality of Life Score and the SF-36 Health Survey. Data were divided into 4 groups of 1-, 2-, 3-, and 4-year follow-ups., Results: The functional scores showed significant postoperative improvement throughout the studied period (p = 0.01). The quality-of-life scores showed a tendency for improvement only in the mental components on the SF-36 Health Survey (p = 0.01). Sixteen patients reported postoperative fecal urgency, but this subsided within a few months. Nine patients reported new postoperative episodes of incontinence and required further treatment., Limitations: This study was limited by its retrospective nature, the selection bias, and a bias by the small number of questionnaires available for some scores., Conclusion: The Transtar procedure was successful for long-term treatment of obstructed defecation syndrome. Fecal urgency and incontinence were observed, but typically resolved within months. Therefore, the Transtar procedure appears to be a reasonable approach to treating obstructed defecation syndrome in the long term.

Background: Previous studies showed that perineal stapled prolapse resection for external rectal prolapse improves continence and has short operation times and low complication rates., Objective: The aim of this study was to assess the midterm recurrence rates, functional results, and patient satisfaction after perineal stapled prolapse resection., Design: This was a retrospective study., Settings: : The study was performed at a tertiary hospital in Switzerland., Patients: From November 2007 to October 2011, a total of 56 consecutive patients were included in the study., Main Outcome Measures: Recurrence rates, functional results according to the Wexner incontinence scale, and patient satisfaction using a visual analog scale were determined., Results: The median age was 78.5 years (range, 24-94 years), and 2 patients were men. Midterm results were available for 46 (82%) of 56 patients after a median follow-up of 25.5 months (range, 2-47 months). In 10 cases (18%) data collection was not possible. The recurrence rate at 3 years was 19.7% (95% CI 4.2%-32.7%). The Wexner incontinence score improved from a median of 14.5 presurgery to 4.0 points (p < 0.0001) after surgery. Twenty-five patients (54%) stated that their bowel movements were regular postoperatively. On a visual analog scale that measured satisfaction, the median patient score was 9 (range, 0-10), indicating high patient satisfaction., Limitations: Limitations included the retrospective study design and the lack of clinical examinations to determine recurrence rates., Conclusions: Perineal stapled prolapse resection is an alternative technique for treating rectal prolapse with a recurrence rate similar to the Altemeier-Mikulicz or Delorme procedures. This technique is a quick and reliable procedure for use in patients with advanced age.

Purpose: Recent studies have reported excellent healing and low recurrence rates for rhomboid flaps for pilonidal sinus disease. The cosmetic outcome has been less investigated and is the focus of this study following Limberg flap reconstruction of recurrent and complex pilonidal disease., Methods: From August 2006 to December 2007 patients with a recurrent or complex pilonidal sinus were enrolled consecutively. All underwent excision and closure with a Limberg flap. At 3 weeks, morbidity was assessed in the outpatient clinic. Recurrence rate, self-esteem, cosmetic outcome, body image, and patient satisfaction were analyzed prospectively at 1 year., Results: Seventy patients (57 males) with a median age of 24.8 years (range, 14.7-46.5) were operated on. Median follow-up was 1.4 years (range, 1.0-2.8). The mean cosmetic score was reduced to 16.4 (± 4.3) of 24, the mean body image score was good with 17.9 (± 2.6) of 20, and the mean overall satisfaction was high at 7.6 (± 2.3) of 10. Self-esteem remained unchanged after surgery; it was 7.8 (± 2.3) preoperatively and 7.8 (± 2.1) postoperatively (P = .818). After 3 weeks 84.3% of the wounds were completely healed. Complications occurred in 18 patients (25.7%), including superficial infection and partial suture dehiscence. Six (8.6%) needed reoperation, and all belonged to the group with acute infection before flap closure (P < .001). There was no incidence of flap necrosis. The recurrence rate was 1.6% at 1-year follow-up., Conclusion: Initial wound closure and low recurrence rates after treatment with Limberg flap in pilonidal sinus disease lead to high patient satisfaction. The cosmetic outcome is acceptable, but an issue for some patients. These results support the use of the Limberg flap in complex pilonidal sinus disease after carefully informing patients about the cosmetic consequences.

Aim: This historical review describes the development of InterStim™ therapy from an open procedure to a minimally invasive technique for the treatment of pelvic floor disorders. The latest technological and surgical evaluations of sacral nerve stimulation (SNS) are presented with their impact on the therapy's success and safety., Method: A search for relevant literature on SNS in the PubMed database was carried out for this review, which focuses on technical modifications and related clinical outcomes., Results: InterStim™ therapy for faecal incontinence was introduced in Europe in 1995. Since its introduction, technical improvements in devices and leads have progressed SNS from an open one-stage procedure to a minimally invasive two-stage technique. A smaller neurostimulator and particularly the new tined lead allow InterStim™ therapy to be performed under local anaesthesia and in an outpatient setting. Additionally, the use of the self-anchoring tined lead has reduced the number of technical failures and improved the test phase significantly, from 60% to 80%. The new smaller-in-size neurostimulator facilitates the implant procedure and further improves patient comfort., Conclusion: By using new technical achievements over the past 15 years, InterStim™ therapy has become a highly effective and safe procedure for selected patients with faecal incontinence., (© 2011 The Author. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Purpose: Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure., Methods: Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey., Results: Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9-22) to 5 (range, 2-10) and the severity of symptoms score, from 16 (range, 9-21) to 4 (range, 0-9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components., Conclusion: Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.

Purpose: Modern sphincter-preserving surgery for ultralow rectal carcinoma has a comparable oncological radicality to abdomino-perineal extirpation (APE). The aim of this study was to assess the long-term morbidity of ultralow anterior resection (ULAR) and its impact on quality of life (QoL) METHODS: The medical records of 142 consecutive patients who underwent surgery for ultralow rectal carcinoma from January 1991 to December 2004 were reviewed retrospectively. The rate of rehospitalisation and rate of non-reversed temporary stomas ("failure" stoma) were analysed. Generic and cancer-specific quality of life questionnaires were used to assess quality of life., Results: There were a total of 82 ULAR and 60 APE. After ULAR, 25 (30.5%) of the patients were readmitted, stenosis and anastomotic leakage being the main reasons. After APE, only 2 (3.3%) of the patients were readmitted (P < 0.001). The rate of patients with a permanent stoma after sphincter-saving surgery was 22.0%. The failure rate was higher for older patients (P = 0.005) and for coloanal pull-through anastomosis (P = 0.001). The exploratory analysis revealed a negative impact of a "failure" stoma on QoL., Conclusion: Severe long-term morbidity and high failure rate of stoma reversal have a significantly worse impact on QoL after ULAR; therefore, APE is a valid alternative to ULAR, especially in elder patients with planned coloanal pull-through anastomosis.

Background: A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up., Methods: From December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour Transtar stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores., Results: 32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (P < 0.0001). No new incidence of constipation was reported., Conclusions: The PSP is an elegant, fast and safe procedure, with good functional results., Trial Registration: ISRCTN68491191.

Sacral nerve stimulation (SNS) is an established treatment for refractory lower urinary tract and bowel dysfunction. In some urological patients, SNS does not have satisfactory results. Pudendal nerve stimulation (PNS) has recently been proposed for these patients and successfully tested. Given the sometimes unsatisfactory results after SNS in fecal incontinence (FI), we tested PNS on patients suffering from FI. We used the device and implantation technique described by Spinelli et al. By making a slight change in the device, we developed a quick and easy-to-use method for successful PNS implantation, based on electrophysiological response. We present the results of a feasibility study, in which we tested the effectiveness of PNS with our modified implantation technique on 2 patients, with very satisfactory early results in a 4-month follow-up.

Background: Radio Frequency Identification (RFID) devices are becoming more and more essential for patient safety in hospitals. The purpose of this study was to determine patient safety, data reliability and signal loss wearing on skin RFID devices during magnetic resonance imaging (MRI) and computed tomography (CT) scanning., Methods: Sixty RFID tags of the type I-Code SLI, 13.56 MHz, ISO 18000-3.1 were tested: Thirty type 1, an RFID tag with a 76 x 45 mm aluminum-etched antenna and 30 type 2, a tag with a 31 x 14 mm copper-etched antenna. The signal loss, material movement and heat tests were performed in a 1.5 T and a 3 T MR system. For data integrity, the tags were tested additionally during CT scanning. Standardized function tests were performed with all transponders before and after all imaging studies., Results: There was no memory loss or data alteration in the RFID tags after MRI and CT scanning. Concerning heating (a maximum of 3.6 degrees C) and device movement (below 1 N/kg) no relevant influence was found. Concerning signal loss (artifacts 2 - 4 mm), interpretability of MR images was impaired when superficial structures such as skin, subcutaneous tissues or tendons were assessed., Conclusions: Patients wearing RFID wristbands are safe in 1.5 T and 3 T MR scanners using normal operation mode for RF-field. The findings are specific to the RFID tags that underwent testing.

We report the case of a 41-year-old female patient who presented in the emergency department with recurrent pain in the lower abdomen 3 years after haemorrhoidopexy (Longo's procedure). At clinical examination a space-occupying mass between the rectum and the vagina was present which was identified as a stool-loaded diverticulum of the rectum by magnetic resonance imaging. Using a perineal approach the diverticulum could be excised at its base and the defect of the mucosa was closed transanally with sutures. A diverticulum of the rectum is a rare complication (2.5%) after stapled haemorrhoidopexy. In the diagnostic of complications after Longo's haemorroidopexy the MRI constitutes an excellent auxiliary modality.

Objective: The stapled transanal rectal resection (STARR) in patients with defecation disorders is limited by the shape and capacity of the circular stapler. A new device has been recently developed, the Contour Transtar stapler, in order to improve the safety and effectiveness of the STARR technique. The study has been designed to confirm this declaration., Method: From January to June 2007 a prospective European multicentre study of consecutive patients with defecation disorder caused by internal rectal prolapse underwent the new STARR technique. The assessment of perioperative morbidity and functional outcome after 6 weeks, 3 and 12 months was documented by different scores., Results: In all 75 patients, median age 64, the Transtar procedure was performed with 9% intraoperative difficulties, 7% postoperative complications and no mortality. The mean reduction of the ODS score was -15.6 (95%-CI: -17.3 to -13.8, P < 0.0001), mean reduction of SSS was -12.6 (95%-CI: -14.2 to -11.2; P < 0.0001). 41% stated improvement of their continence status by CCF score, only 4 patients (5%) had deterioration., Conclusion: The Transtar procedure is technically demanding, with good functional results similar to the conventional STARR.

Background: Patients with a rectocele often suffer from such symptoms as obstructed defaecation, urine or stool incontinence and pain. The aim of this study was to assess other concomitant pelvic floor disorders and their influence on pelvic function., Methods: Included in the study were 37 female patients with a significant rectocele and defaecation disorder. Medical history and symptoms were analysed in terms of validated functional scores. All patients underwent open magnetic resonance defaecography (MRD) in a sitting position. Imaging was analysed for the presence and size of the rectocele, intussusception and other pelvic floor disorders., Results: Patients with a higher body mass index tended to have a larger rectocele, whereas age and vaginal birth did not correlate with the size of the rectocele. In 67.5% of the patients with a previously diagnosed rectocele, an intussusception was diagnosed on MRD. This group suffered from significantly worse urine incontinence (p=0.023) and from accessory enteroceles 64%, compared with 17% (p=0.013) for those with a simple rectocele. Patients with higher grade intussusception suffered more frequently from incontinence than from constipation., Conclusion: Patients with a symptomatic rectocele frequently have other pelvic floor disorders that significantly influence the pattern of symptoms. Knowledge of all the afflictions is essential for determining the optimal treatment for each individual patient.

Purpose: The clinical and morphologic outcome of patients with obstructed defecation syndrome after stapled transanal rectal resection was prospectively evaluated., Methods: Twenty-four consecutive patients (22 women; median age, 61 (range, 36-74) years) who suffered from obstructed defecation syndrome and with rectal redundancy on magnetic resonance defecography were enrolled in the study. Constipation was assessed by using the Cleveland Constipation Score. Morphologic changes were determined by using closed-configuration magnetic resonance defecography before and after stapled transanal rectal resection., Results: After a median follow-up of 18 (range, 6-36) months, Cleveland Constipation Score significantly decreased from 11 (range, 1-23) preoperatively to 5 (range, 1-15) postoperatively (P = 0.02). In 15 of 20 patients, preexisting intussusception was no longer visible in the magnetic resonance defecography. Anterior rectoceles were significantly reduced in depth, from 30 mm to 23 mm (P = 0.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of the 24 patients; however, only two were severe (1 bleeding and 1 persisting pain requiring reintervention)., Conclusions: Clinical improvement of obstructed defecation syndrome after stapled transanal rectal resection correlates well with morphologic correction of the rectal redundancy, whereas correction of intussusception seems to be of particular importance in patients with obstructed defecation syndrome.

Purpose: A perineal approach to treating rectal prolapse is ideal for frail patients. Recently, internal rectal redundancy has been successfully treated with transanal resection using the Contour Transtar stapler. This technique has been modified to the perineal stapled prolapse resection. The surgical technique and the preliminary results of the new procedure for external rectal prolapse are presented., Methods: Patients not suited for transabdominal treatment were included prospectively for perineal stapled prolapse resection in two colorectal centers. Feasibility, complications, and reinterventions were assessed., Results: In 14 of 15 patients, perineal stapled prolapse resection was performed without complications in a median operating time of 33 (range, 22-52) minutes. One procedure was changed to an Altemeier because of a staple line disruption. Two patients required reintervention as a result of postoperative hemorrhage. No other severe complications occurred. At follow-up, all patients were well and showed no early recurrence of prolapse., Conclusions: Perineal stapled prolapse resection is a new surgical procedure for external rectal prolapse, which is easy and quick to perform. Functional results and long-term recurrence rate must be investigated further.

We report a case of a recto-urethral fistula in Crohn's disease. In our case, suprapubic cystostomy, ciprofloxacin, metronidazole, and azathioprine led to complete remission. Recto-urethral fistulas due to Crohn's disease are very uncommon. Pneumaturia, faecaluria, urinary tract infection, dysuria, and urethral discharge are the most common complaints. After complete diagnostics, immunosuppressive therapy in complicated Crohn's disease is of increasing importance. It is recommended to continue treatment after healing to prevent further complications.

Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings in patients suffering from refractory constipation that may be best characterized as obstructive defecation syndrome. However, there is still no clear evidence whether the stapled transanal rectal resection (STARR) procedure provides a safe and effective surgical option for symptom resolution in patients with obstructive defecation syndrome, as evidence-based guidelines and functional long-term results are still missing. On the basis of the need for objective evaluation, a European group of experts was founded (Stapled Transanal Rectal Resection Pioneers). Derived from 2 meetings (October 26-28, 2006, Gouvieux, France and November 28-29, 2007, St Gallen, Switzerland) a concept for treatment options in patients suffering from obstructive defecation syndrome was developed, including a clear decision-making algorithm specifically focusing on the role of the stapled transanal rectal resection procedure based on clinical symptoms and dynamic imaging and inclusion and exclusion criteria for the stapled transanal rectal resection procedure.

Background: Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer., Methods: Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups., Results: Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0.402 for major and P = 0.691 for minor complications). Median number of lymph nodes removed was 7 (range 1-22) for EPMR and 11 (range 2-36) for LAR (P = 0.132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence., Conclusion: EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone., (2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background and Aims: Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage., Materials and Methods: Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3-4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively., Results/findings: No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023)., Interpretation/conclusion: Patient's safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.

Objective: The objective of our study was to compare intraindividually two rectal enema compositions in MR defecography., Materials and Methods: Twenty patients underwent MR defecography twice on a 0.5-T open-configuration system in the sitting position. During the first imaging session, MR defecography was performed with a rectal enema consisting of potato starch mixed with gadolinium (PS group). During the second session, the enema consisted of ultrasound gel mixed with gadolinium (US group). The imaging protocol consisted of midsagittal T1-weighted gradient-recalled echo MR images obtained at rest, at maximal sphincter contraction, at straining, and during defecation. All images were analyzed quantitatively by measuring the contrast-to-noise ratio (CNR) and reviewed by three independent observers with regard to the visibility of pelvic floor abnormalities and the extent of those abnormalities., Results: The CNR values in the PS group (mean +/- SD, 167.49 +/- 44.4) were significantly higher than those obtained in the US group (150.2 +/- 37.8) (p < 0.05). The visibility scores for anterior rectoceles and intussusceptions were higher in the PS group than in the US group (mean visibility scores: PS group, 2.8 +/- 0.42 and 2.6 +/- 0.56, respectively; US group, 2.3 +/- 0.77 and 2.2 +/- 0.74, respectively). The size and the number of incompletely emptying anterior rectoceles were higher in the PS group., Conclusion: Ultrasound gel and potato starch provide good contrast and depiction of relevant pelvic floor abnormalities. However, the visibility of pelvic floor abnormalities and extent of those abnormalities depend on the composition of the rectal enema. In particular, the size and degree of anterior rectocele evacuation and intussusception size are often underestimated when ultrasound gel is used for rectal enema.

Background and Aims: Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT)., Materials and Methods: Between January 2001 and August 2004, 40 patients (21 women), median age 37 years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10 U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6 weeks after the operation. At 1 year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results., Results/findings: At 6 weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1 year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%., Interpretation/conclusion: Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rate.

Symptomatic pilonidal sinus is characterized by an acute or a chronic inflammation. The surgical management of symptomatic pilonidal sinus is still a matter of discussion and no clear recommendations exists. On the basis of results from published studies and our own experience we developed a new two step therapy concept: Infected pilonidal were first drained by a small excision of the abscess (if possible in local anesthesia) followed by a close fistula excision. With this approach we were able to achieve a low morbidity and a high healing rate. In the case of extensive fistulating pilonidal sinus or recurrent disease we recommend radical excision and primary reconstructive flap what showed good aesthetic results.

Hypothesis: Permanent sacral nerve stimulation (SNS) is a promising emerging treatment for fecal incontinence. However, there is little data on morbidity and quality of life (QOL) during long-term stimulation., Design: Prospective trial to assess morbidity and QOL in patients treated with SNS. Median follow-up was 13 months (range, 1-42 months)., Setting: University hospital providing primary, secondary, and tertiary care., Patients: Between December 2001 and July 2005, SNS was tested in 44 patients (30 women), with a median age of 65 years (range, 15-88 years)., Interventions: Percutaneous nerve evaluation and permanent insertion of an implantable pulse generator., Main Outcome Measures: Morbidity, stool diary, and Wexner Score for fecal incontinence; Hanley Score for urinary incontinence; and Gastrointestinal Quality of Life Index, the 36-item short form health survey, and the Royal London Hospital questionnaire for QOL., Results: A permanent stimulator was implanted in 37 patients (84%). Eight patients (22%) experienced complications that required surgical intervention. (A successful restimulation was possible for 5 of those patients.) Adverse effects of SNS were remedied in 5 patients by reprogramming the stimulator. Wexner Scores decreased from a median of 16 points preoperatively (range, 6-20), to a median of 5 points postoperatively (range, 0-13; P<.001). The median number of involuntary stool losses and for urge defecations also decreased significantly. Significant improvement in QOL was found in both generic and incontinence-specific questionnaires (P<.05). The success rate of SNS was 77% (34 of 44 patients) and 92% (34 of 37) in patients with permanent implantation., Conclusions: The minimally invasive technique of SNS is safe and effective. Most adverse effects can be easily remedied. Our data demonstrate that SNS significantly improves patients' QOL, including their physical and psychological well-being.

Background: Sacral nerve stimulation (SNS) may be successful in treating incapacitating faecal incontinence. The technique is expensive, and no cost analysis is currently available. The aim of this study was to assess clinical outcome and analyse cost-effectiveness., Methods: Thirty-six consecutive patients underwent a two-stage SNS procedure. Outcome parameters and real costs were assessed prospectively., Results: SNS was tested successfully in 33 of 36 patients, and 31 patients were stimulated permanently. In the first stage, eight of 36 patients reported minor complications (pain, infection or electrode dislocation), resulting in a cost of euro 4053 (range euro 2838-7273) per patient. For the second stage (permanent stimulation), eight of 33 patients had an infection, pain or loss of effectiveness, resulting in a cost of euro 11,292 (range euro 7406-20,274) per patient. Estimated costs for further follow-up were euro 997 per year. The 5-year cumulative cost for SNS was euro 22,150 per patient, compared with euro 33,996 for colostomy, euro 31,590 for dynamic graciloplasty and euro 3234 for conservative treatment., Conclusion: SNS is a highly cost-effective treatment for faecal incontinence. Options for further reduction of SNS costs include strict patient selection, treatment in an outpatient setting and using cheaper devices.

Purpose: To retrospectively evaluate magnetic resonance (MR) defecography findings in patients with fecal incontinence who were evaluated for surgical treatment and to assess the influence of MR defecography on surgical therapy., Materials and Methods: Institutional review board approval was obtained. Informed consent was waived; however, written informed consent for imaging was obtained. Fifty patients (44 women, six men; mean age, 61 years) with fecal incontinence were placed in a sitting position and underwent MR defecography performed with an open-configuration MR system. Midsagittal T1-weighted MR images were obtained at rest, at maximal contraction of the sphincter, and at defecation. Images were prospectively and retrospectively reviewed by two independent observers for a variety of findings. Interobserver agreement was analyzed by calculating kappa statistics. Prospective interpretation of MR defecography findings was used to influence surgical therapy, and retrospective interpretation was used for concomitant pelvic floor disorders., Results: MR defecography revealed rectal descent of more than 6 cm (relative to the pubococcygeal line) in 47 (94%) of 50 patients. A bladder descent of more than 3 cm was present in 20 (40%) of 50 patients, and a vaginal vault descent of more than 3 cm was present in 19 (43%) of 44 women. Moreover, 17 (34%) anterior proctoceles, 16 (32%) enteroceles, and 10 (20%) rectal prolapses were noted. Interobserver agreement was good to excellent (kappa = 0.6-0.91) for image analysis results. MR defecography findings led to changes in the surgical approach in 22 (67%) of 33 patients who underwent surgery., Conclusion: MR defecography may demonstrate a variety of abnormal findings in patients who are considered candidates for surgical therapy for fecal incontinence, and the findings may influence the surgical treatment that is subsequently chosen., Supplemental Material: http://radiology.rsnajnls.org/cgi/content/full/2402050648/DC1, (RSNA, 2006)

Background: Sacral nerve simulation (SNS) is an accepted therapy for patients with urinary or bowel dysfunction. However, infection rates are as high as 20% and can result in removal of the expensive device. We present a new video-assisted technique minimizing the risk of infection., Methods: Between April and July 2005, six consecutive women of median age 68 years (range, 60-74), with faecal incontinence (4 patients) and idiopathic constipation (2 patients) underwent video-assisted electrode implantation for SNS. The motor response of the pelvic floor during percutaneous nerve evaluation and implantation of the permanent lead was monitored by a video optic (same as that normally used for laparoscopic or endoscopic procedures) placed between the legs of the patients. The video optic and the perianal area were completely covered with drapes, separating them from the operating field., Results: All but one screening was successful, and no wound infections at the electrode or at the pocket of the stimulator were noted (mean postoperative follow-up, 8 weeks)., Conclusions: With the use of a video optic, the anus and the implantation site can be completely separated and contamination during the operation becomes unlikely. Furthermore, the response of the pelvic floor to the stimulation is better visualized. We routinely recommend the use of video equipment for SNS electrode implantation.

The sacral nerve stimulation is a new promising procedure for faecal incontinence in patients in whom conservative treatments have failed. In contrast to more invasive restorative surgeries (e.g. dynamic graciloplasty or artificial sphincter), sacral nerve stimulation can be tested and performed in outpatient under local anaesthesia. From May 2001 to April 2004, 25 consecutive patients with faecal incontinence underwent percutaneous test-stimulation during 10 to 14 days. The test was positive in 16 of them (64%) in whom a permanent implantation of an internal pulse generator was performed. During the follow up of this group a significant reduction of the number of incontinence episodes and a considerable improvement of quality of life was demonstrated. Complete investigations and restrictive patient selection, as well as a carefully follow up are recommended for the success in sacral nerve stimulation therapy.

Background: The purpose of this study was to assess the influence of the type of anaesthesia (local vs. general) and of the electrode used (test electrode vs. tined lead) on a successful screening period., Methods: Between May 2001 and January 2004, we performed 25 percutaneous nerve evaluation (PNE) tests in 20 patients (11 women). The first 15 PNE tests were followed by introducing a conventional electrode, and since 2003 by a tined lead electrode. Success was defined as reduction of symptoms by more than 50%., Results: A stimulator was implanted in 13 (68%) patients, including 4 of 14 screened with the conventional electrode and 9 of 10 screened with tined lead electrode (p=0.005). Eleven (44%) of the PNE tests were done under local anaesthesia, but the success rate was not influenced by the type of anaesthesia (local 46% vs. general 61%, p=0.682)., Conclusions: PNE testing and implantation of the tined lead electrode can be easily performed at the same time under local anaesthesia. The use of the new tined lead electrode significantly increased the success rate for the screening phase.

Objective: The Délorme's operation for rectal prolapse is a safe procedure but has a high recurrence rate. We aimed to develop an operation akin to it, but designed to reduce this deficit., Patients and Methods: Thirty-one consecutive patients with rectal prolapse were included in the study. Initially, a conventional Délorme's procedure was performed and sutures or strips of Gore-Tex were attached circumferentially to the apex of the prolapse, tunneled subcutaneously, and anchored to the external surface of the pelvis. Subsequently, the procedure was modified. Acellular porcine collagen strips were used and buried within the apex without plication of the denuded rectal musculature. Patients were formally assessed preoperatively and four months postoperatively by symptom and quality of life questionnaires and subsequently by regular clinical review., Results: In the Gore-Tex group (N = 11; males:females = 10:1; mean age, 61 years) three patients underwent suture repair and eight had strip fixation. All suture repairs developed sepsis and one patient had a recurrence. Seven of the strip fixations (88 percent) developed sepsis that resulted in implant extrusion. There was one full-thickness and one mucosal recurrence after a median follow-up of 25 months. In the collagen group (N = 20; males:females = 2:18; mean age, 63 years), sepsis occurred in four patients, requiring surgical intervention in one patient (5 percent) (cf Gore-Tex group, P = 0.002). There was one mucosal and three full-thickness (15 percent) recurrences after a median follow-up of 14 months (cf Gore-Tex group, P = not significant). Significant improvements in symptom and quality of life scores were recorded in both groups at four months., Conclusion: A new, minimally invasive perineal procedure for rectal prolapse has been developed and initial data testify to its relative safety provided collagen is used. It remains to be seen whether long-term recurrence rates will be lower than those of conventional perineal procedures.

We present a 25-year-old, HIV-negative patient from Kosovo, with no significant past medical history, who was admitted to a local hospital for nonspecific upper abdominal discomfort. He was transferred to us after a retroperitoneal mass with contact to the right colonic flexure had been found during workup. Colonoscopy demonstrated an edemateous area with a central fistula in the right flexure, and histology showed caseous necrosis. Although neither bacteriology nor histology could detect any germs, gastrointestinal tuberculosis seemed to be very probable. Laparotomy with a segmental resection of the colon was performed to remove the fistula-bearing segment, and histologic examination of the resected specimen confirmed the intraoperative suspect of a retroperitoneal colonic perforation. Again, all cultures from the specimen were negative for tuberculosis, but polymerase chain reaction of a regional lymph node revealed acid-fast bacilli of the Mycobacterium tuberculosis/bovis species. Although the patient had no other sites of tuberculosis infection like pulmonary or urinary, he received adjuvant standard tuberculosis treatment for six months. At control examination one year after the operation, the patient was free of recurrence and in very good general condition. We report this extremely rare presentation of gastrointestinal tuberculosis to sensitize physicians to tuberculosis again, because incidence rates are increasing and this disease will certainly play a more important role in the future.