Seminars in Colon and Rectal Surgery最新文献

Rectal prolapse is often accompanied by pelvic organ prolapse. The surgeon needs to be astute in order to elicit the symptoms and perform the appropriate exam in order to fully evaluate the pelvic floor. This is often a daunting task, and the immediate response is to refer to our urogynecology colleagues. However, with the knowledge of the individual tests, the purpose of each test, and a systematic approach to performing the comprehensive assessment every provider can and should be able to complete a full pelvic floor exam. In this chapter, we present a stepwise approach to performing a comprehensive multicompartment pelvic floor examination, as well as understanding the common terminology across the treatment team and critical components for the consultation. There is a full consort of physical examinations every patient with pelvic organ or rectal prolapse should undergo, and collaboration across specialties is needed to ensure this comprehensive and complete evaluation is performed. Every surgeon is not expected to perform every test, but significant multicompartment pelvic floor prolapse benefits from a multidisciplinary team to ensure a thorough evaluation is done. But with the information in this chapter, colorectal surgeons should feel comfortable completing the initial examinations, treatment regimens, and eliciting proper referrals for best care of prolapse.

Patients attending the pelvic floor clinic may have symptoms of defaecatory, urinary and sexual dysfunction, including incontinence and prolapse. Pelvic floor dysfunction is multifactorial and multi-compartmental. A holistic approach which addresses all aspects and compartments is essential to achieve optimal assessment and outcomes. The team must be multidisciplinary and cohesive, with open channels of communication and discussion. A multidisciplinary clinic provides a platform to ensure an efficient pathway for the patient and healthcare system, all aspects of care are simultaneously addressed, and patient care is optimised. This section outlines the drivers for, and potential outcomes from, running a multidisciplinary clinic.

The operative management of rectal prolapse has evolved substantially over time. Many patients with rectal prolapse also have concomitant prolapse of their anterior and/or middle compartments. Optimal repair of pelvic organ prolapse will address all of the involved compartments, which often requires close collaboration with a urogynecology or female urology team. This chapter describes our technique for robotic ventral mesh rectopexy with sacrocolpopexy when indicated.

Pelvic floor disorders are common conditions that affects mainly the female population, especially the elderly. Anorectal physiology and imaging tests are important way to assess anal sphincter function and structure of the pelvic floor. Those tests are part of the workup for patients with incontinence, defecatory disorders and pelvic organ prolapse. The most relevant tests will be discussed in this article.

Rectal Intussusception (RI) occurs when the rectal wall telescopes distally without prolapse past the anal verge during defecation and occurs as the result of abnormal rectal wall biomechanics. Symptoms are variable though ¾ of patients with high grade intussusception report straining, incomplete emptying and the need for manual assistance during evacuation. The diagnosis of RI requires a comprehensive clinical history, physical exam and dynamic imaging of evacuation with MR or fluoroscopic defecography. Phenotypic grading is important as low-grade, non-obstructing RI may not significantly contribute to symptoms and outcomes following surgery in this group is poor. Initial management should focus on improving stool form and evacuatory dynamics in conjunction with biofeedback if there associated dyssynergia. Surgery should only be considered in those patients with high-grade intussusception and symptoms resistant to medical therapies after appropriate counselling regarding the risks and benefits of intervention.

Introduction

The Cleft Lift procedure originally named by Bascom is a derivative of the Karydakis flap procedure for pilonidal sinus disease. The terminology and variations of the name have long confused surgeons and have limited its wide adoption.

Technique

This technical paper deconstructs the confusing terminology, suggests simple steps for success, and proposes a more descriptive name for the asymmetric flap procedure which has the lowest reported recurrences for all surgical options for pilonidal disease.

Results

The author has successfully performed the Cleft Lift procedure for pilonidal disease since 2000. In the last consecutive 757 patients treated over 12 years, only 6 patients have required a second operation. This cohort included 287 patients referred with recurrent disease or open wounds from prior pilonidal surgery. A new naming scheme is proposed that more accurately describes the operation. The proposed name is the pilonidal RAF procedure for rotation (around the anus) and advancement (across the natal cleft midline) flap .

Conclusions

The pilonidal RAF procedure is highly successful in treating pilonidal sinus disease with a very low need for additional surgery even in complex recurrent disease.

Sacrococcygeal pilonidal disease is common in the pediatric population and its incidence is increasing. Psychological stigmatization is common. Adolescent patients have unique challenges in body image, communication with family members and caregivers, and hygienic practices. Acute infection requires antibiotics and abscess require drainage. Chronic disease is managed with noninvasive therapies or minimally invasive surgical debridement procedures, which may be repeated for simple recurrences. Larger excision and off-midline flap reconstructions are reserved for complex and extensive disease or multiple recurrences that are refractory to less invasive excisional techniques. Common presentation of pediatric pilonidal disease, available therapies, anticipated outcomes, and a suggested treatment algorithm are presented in this article.

Pilonidal disease (PD) is a common suppurative condition located beneath the skin of the sacrococcygeal region. Diagnosis is clinical and usually doesn't require any instrumental examination or imaging. To date, there is still no gold standard treatment for symptomatic PD, although most clinicians advocate surgical excision as a definitive treatment. Recently, several comparative studies between traditional excision and minimally invasive techniques have been published. However, there are still methodological limitations and selection biases that prevent the achievement of an adequate level of scientific evidence. The main advantages of the minimally invasive procedures include fewer wound infections, less pain, quicker return to work, and higher patient satisfaction. However, the success rate is still unclear and further studies are needed. This article briefly highlights the different minimally invasive approaches introduced in the last years, including both the endoscopic treatment and the laser surgery.

Pilonidal disease is a chronic inflammatory disease which has significant negative impact on quality of life. Numerous treatment methods have been described for pilonidal sinus disease. However recurrence is a major concern for both patients and healthcare providers. More aggressive surgical methods such as flap-based off-midline procedures are the most common surgical treatment methods for complex or recurrent pilonidal disease. The Limberg flap is one of the best described flap-based surgical methods. In this review, we highlight the technical details and postoperative short and long-term outcomes of the Limberg flap procedure which is our preferred surgical technique, with low rates of complications and recurrence.