[Show abstract][Hide abstract] ABSTRACT: Laparoscopy offers great exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing and bowel manipulation making it an excellent modality to perform pelvic floor surgery. Laparoscopic repair of level I or apical vaginal prolapse may be challenging, due to the need for extensive dissection and advanced suturing skills. However it offers the efficacy of open abdominal sacrocolpopexy, such as lower recurrence rates and less dyspareunia than sacrospinous fixation, as well as the reduced morbidity of a laparoscopic approach.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopy offers great exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing-- and bowel manipulation making it an excellent modality to perform pelvic floor surgery. Laparoscopic repair of level I or apical vaginal prolapse may be challenging, due to the need for extensive dissection and advanced suturing skills. However, it offers the efficacy of open abdominal sacrocolpopexy, such as lower recurrence rates and less dyspareunia-- than sacrospinous fixation, as well as the reduced morbidity of a laparoscopic approach.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopy may yield better exposure and surgical detail, reduce blood loss and the need for excessive abdominal packing
and bowel manipulation, which may all lead to a lesser morbidity.1 Laparoscopy has now also found its way to the field of urogynecology. Recently, laparoscopic colposuspension was shown to
be equally effective as an open procedure at 2-years follow-up.2 Whereas colposuspension as primary therapy for urinary stress incontinence is on its way back, because of a lesser invasive
and equally effective vaginal approach, other urogynecologic procedures may still benefit from an abdominal approach. Surgical
repair of level I or apical vaginal defects, that also preserves vaginal function, can be performed either vaginally or through
abdominal approach.3 Randomized trials, however, have shown that sacrocolpopexy offers lower recurrence rates and less dyspareunia than sacrospinous
fixation, but at the expense of a longer recovery time.4 Logically, laparoscopic sacrocolpopexy (LSC) may reduce the latter morbidity. LSC was embraced later than colposuspension,
probably because vault prolapse occurs more rarely and LSC needs extensive dissection and advanced suturing skills.5 Data on LSC initially were limited to observational studies of variable size.6–14 They covered issues such as perioperative parameters, reported short-term results, and were usually retrospective in design.
[Show abstract][Hide abstract] ABSTRACT: Magnetic resonance imaging (MRI) is used to assess the outcome of infliximab (IFX) therapy in patients with perianal fistulizing Crohn's disease (pfCD). However, few long-term data are available about its efficacy.
We assessed 59 patients with pfCD by MRI and clinical evaluation at baseline. Treated patients then received paired clinical and MRI examinations for a median time period of 36 (11-53.3) weeks. Short-, mid-, and long-term effects of therapy, as well as the ability of MRI to predict treatment outcome and need for surgery, were evaluated.
Compared with the baseline MRI, the short-term follow-up MRI (n = 29) revealed a reduced number of fistula tracks in 13.8% and in the inflammatory activity in 55.2% of patients, respectively; mid-term MRI (n = 25) in 56% and in 52%, respectively; and long-term MRI (n = 13) in 15.4% and in 31%, respectively. Improvement of pfCD based on MRI results coincided with clinical improvement in 54.7% of the patients. Short-term and mid-term (but not long-term) MRI showed a significant decrease in the activity score. Therapy outcome was worse among patients with persisting fistulas (P = .01), collections (P = .009), and rectal wall involvement (P = .01) in the final MRI. Patients with single-branched fistulas (P < .0001) and collections (P = .006) in their baseline MRI were more likely to undergo surgery.
MRI is a useful technique for evaluation of pfCD during the first year of follow-up. In the long-term, the MRI improvement coincides with clinical and endoscopic response to IFX in 50% of the patients.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 11/2010; 9(2):130-6. DOI:10.1016/j.cgh.2010.10.022 · 7.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing.
Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment.
Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients.
Fistula closure was achieved in most patients, but more than one operation was often required.
British Journal of Surgery 10/2009; 96(10):1190-5. DOI:10.1002/bjs.6661 · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Endoscopic dilatation of Crohn's disease-related strictures is an alternative to surgical resection in selected patients. The influence of disease activity and concomitant medical therapy on long-term outcomes is largely unknown.
To study the long-term safety and efficacy of stricture dilatation in a single centre cohort.
Between 1995 and 2006, 237 dilatations where performed in 138 patients (mean age 50.6+/-13.4, 56% female) for a clinically obstructive stricture (<5 cm, 84% anastomotic). Immediate success of a first dilatation was 97% with a 5% serious complication rate. After a median follow-up of 5.8 years (IQR 3.0-8.4), recurrent obstructive symptoms led to a new dilatation in 46% or surgery in 24%. Niether elevated levels of C-reactive protein nor endoscopic disease activity predicted the need for new intervention. None of the concomitant therapies influenced the outcome.
This largest series ever reported confirms that long term efficacy of endoscopic dilatation of Crohn's disease outweighs the complication risk. Neither active disease at the time of dilatation nor medical therapy afterwards predict recurrent dilatation or surgery.
Gut 10/2009; 59(3):320-4. DOI:10.1136/gut.2009.180182 · 14.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We compared the medium term anatomical and subjective outcome, and graft related complications after sacrocolpopexy for apical vaginal prolapse using xenogenic or polypropylene grafts.
We prospectively studied 50 consecutive patients who underwent laparoscopic sacrocolpopexy with porcine grafts of small intestinal submucosa (21) or dermal collagen (29). We compared these patients to 100 consecutive controls in whom polypropylene was used, and underwent surgery before (50) or after (50) the cases. The primary outcome was anatomical cure (stage I or less at any compartment). Secondary outcomes were graft related complications, subjective cure and quality of life evaluated by clinical examination, standardized interview and prolapse specific questionnaire, respectively.
At study closure 129 (86%) patients were available for functional evaluation and 104 (67%) were available for anatomical evaluation. Mean postoperative followup (+/-33 months) and baseline characteristics except age were comparable. The overall anatomical failure rate was comparable (49% vs 34%, p = 0.053) but failures at the vault (21% vs 3%, p <0.01) and posterior compartment (36% vs 19%, p <0.05) were more frequent in the xenograft group. There were 6 reoperations including secondary laparoscopic sacrocolpopexy (5) and cystocele repair (1), all confined to the xenograft group (p <0.01). Graft related complications were equally frequent (11%) in the xenograft and polypropylene groups. The reoperation rate for graft related complications was not different (xenograft 3% vs controls 11%, p = 0.20). There were no differences in functional outcome and quality of life between xenografts and controls.
While overall anatomical failure was comparable, sacrocolpopexy using xenograft was associated with more apical failures and reoperations for prolapse than with polypropylene without differences in functional outcome. The use of xenografts did not decrease the number of graft related complications.
The Journal of urology 09/2009; 182(5):2362-8. DOI:10.1016/j.juro.2009.07.043 · 4.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cidofovir, a nucleotide analog with antiviral activity against a broad range of DNA viruses including human papilloma viruses (HPV), is available off label to clinicians.
To provide a better knowledge of pharmacology and effects when topically applied.
After reviewing the chemistry, physiology, and animal studies, an overview of clinical studies is provided.
Cidofovir, as a result of its antiviral and antiproliferative activity and its ability to induce apoptosis, can offer a solution for the treatment of severe recurrent HPV-induced lesions. It can also be used to attempt to treat dysplastic lesions and as an adjuvant treatment. The long-lasting antiviral activity allows infrequent dosing. As a rule, cidofovir applied on the skin is well tolerated, even in long-term treatment. The dose-limiting nephrotoxicity of the drug is not a concern in patients with a glomerular filtration rate within the normal range. Cidofovir has clearly influenced the landscape of refractory and dysplastic anogenital condylomata acuminata and its use has increased over the last decade. However, further controlled clinical trials are needed to assess the role of cidofovir and its derivatives.
[Show abstract][Hide abstract] ABSTRACT: Limited prospective data on the anatomic and functional outcome after laparoscopic sacrocolpopexy (LSC) are available in the literature.
To describe the medium-term anatomic and functional outcome of LSC.
Prospective consecutive series of 132 women with vaginal vault prolapse undergoing LSC between 2001 and 2006, which was after our learning curve. Patients with urodynamically proven stress incontinence (SI) underwent a concomitant tension-free vaginal tape (TVT) procedure.
Patients underwent LSC with a polypropylene implant.
Principal outcome measures were anatomic cure (stage 1 or lower) assessed by the Pelvic Organ Prolapse Quantification (POPQ) system and subjective cure and impact on quality of life measured by a standardised interview and, since its introduction in 2004, by a prolapse-specific quality-of-life questionnaire (P-QOL).
At a mean follow-up of 12.5 mo, the anatomic cure rate for the apex was 98%. Anatomic failures elsewhere were mainly at the posterior compartment (18%). Subjective prolapse cure rate was 91.7%, and no patients required reoperation for recurrent prolapse. Symptoms of preoperative SI, urge incontinence, or constipation were cured in 43%, 46%, and 42% of patients, respectively. The rate of de novo SI was 7.3%. De novo constipation developed in 5% and de novo dyspareunia developed in 19%. Patients' quality of life improved significantly. Erosions occurred in 4.5%, all within 1 yr. A limitation of the study is that the quality-of-life assessment score became available halfway through the study, limiting the number of preoperative observations (n=36).
We demonstrated that LSC results in good anatomic outcome and subjective cure of prolapse symptoms at medium term. The posterior compartment was most vulnerable for recurrence.
European Urology 06/2009; 55(6):1459-67. DOI:10.1016/j.eururo.2008.12.008 · 13.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We studied the long-term anatomical and functional outcome following sacrocolpopexy for apical vaginal prolapse using xenogenic grafts in a population at increased risk for graft-related complications (GRCs).
Twenty-two consecutive patients with symptomatic apical prolapse were scheduled for laparoscopic sacrocolpopexy (LSC) with porcine grafts because they were presumed to be at risk for GRC, because of pre-existing vaginal ulcerations (n = 4), concomitant vaginal prolapse repair (n = 15), total hysterectomy (n = 1), or intra-operative abdominal contamination due to accidental laceration of the vagina, bowel perforation (n = 1) or the presence of infection (n = 1). Either small intestinal submucosa (n = 8) or dermal collagen (n = 14) was used. Outcome measures were GRCs, anatomical cure (<or=Stage I at any compartment), subjective cure, impact on bowel, bladder, and sexual function measured by a standardized interview.
At study closure 20 (91%) patients were available for functional evaluation and 16 (73%) for anatomical evaluation at a mean follow-up period of 27.4 months. The GRC rate was 25% (n = 4) prompting reintervention in half, and including two patients with spondylodiscitis. The anatomical cure rate was 31.5%. Failures at the vault, anterior, and posterior compartments occurred in, respectively, 31%, 18.8%, and 50% of patients. The subjective cure rate was 60% and three patients (15%) underwent redo-LSC.
The strategy of using xenografts in patients at risk for GRC, did not prevent these to occur and was associated with a high anatomical and functional failure rate as well as reoperation rate.
Neurourology and Urodynamics 01/2009; 29(4):563-7. DOI:10.1002/nau.20805 · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Chronic constipation is a common condition that is difficult to treat. Existing options for the treatment of patients with different subgroups of constipation are limited. A new efficacious and safe drug is needed to limit the frequently observed adverse effects induced by laxatives, to improve general wellbeing and quality of life, and to provide an alternative for enemas or even resectional surgery in patients in whom stimulant laxatives cause disabling adverse effects or fail to increase bowel movement frequency. AIMS: The purpose of this article is to assess the current evidence supporting the use of the selective and high affinity serotonin-4 (5-HT(4)) receptor agonist prucalopride in the management of chronic constipation. EVIDENCE REVIEW: There are now convincing data from phase II and multicenter phase III randomized, double-blind, placebo-controlled trials that prucalopride treatment results in a clinically meaningful increase in the number of spontaneous complete bowel movements, a reduction of perceived severity of symptoms and improved disease-related quality of life in a significant proportion of patients. There is a rapid onset of the effect and the improvement is maintained for at least 12 weeks. Prucalopride in a dose of up to 4 mg per day appeared generally well tolerated and devoid of serious cardiac events. Adverse events, most frequently headache and nausea, are usually mild or moderate and occur mainly during the first days of treatment. Prucalopride should be used with prudence and with careful assessment of the benefit-risk ratio until more clinical and electrophysiologic data become available, because relatively few patients have been exposed to the drug for long periods of time. PLACE IN THERAPY: Prucalopride 1-2 mg once daily may be given to patients suffering from chronic constipation for whom laxatives do not provide adequate relief of their symptoms. Patients with severe constipation and slow transit, who frequently develop tolerance to stimulant laxatives, are also eligible for prucalopride treatment.
[Show abstract][Hide abstract] ABSTRACT: We report a case of uterine prolapse in a young woman, treated by posterior intravaginal slingplasty with preservation of the uterus as a feasible and safe surgical procedure. Posterior intravaginal slingplasty is commonly used to correct vaginal vault prolapse, but may be a valuable alternative to correct uterine prolapse. We compare this technique to other techniques to correct uterine prolapse.
[Show abstract][Hide abstract] ABSTRACT: Irritable bowel syndrome (IBS) is associated with significant morbidity, impaired quality of life, work absenteeism and high healthcare costs. Current drug treatments, with the exception of drugs targeting serotonin receptor subtypes, are of limited value. Tegaserod (Zelnorm™, Novartis Pharmaceuticals Corp., NJ, USA), a partial agonist, is useful in women with the constipation-predominant form of IBS. Alosetron (Lotronex™, GlaxoSmithKline plc, London, UK), a 5-HT3 receptor antagonist, is effective in women with severe diarrhea-predominant IBS; however, its use is limited and it is restricted to the USA. Cilansetron is a potent and selective 5-HT3 receptor antagonist that is being developed for IBS with diarrhea predominance (IBS-D). It delays colonic transit and reduces visceral hypersensitivity. In large, randomized controlled trials, cilansetron has been shown to improve global and specific IBS-D symptoms, including abdominal pain/discomfort, stool frequency, stool consistency, urgency and health-related quality of life in men and women. Cilansetron is well-tolerated, with constipation being the most frequent adverse event. Treatment with cilansetron, similar to that with alosetron, is associated with a low incidence of suspected ischemic colitis events. Alosetron was withdrawn temporarily from the US market, and indefinitely from the European market because of severe complications of ischemic colitis. To date, the few suspected ischemic colitis events associated with cilansetron have resolved within 30 days of drug discontinuation, without any complications. Epidemiologic studies indicate that patients with IBS have a greater risk of ischemic colitis, irrespective of treatment; this underscores the need for additional research on the natural history of IBS and potential treatment-related adverse events.
[Show abstract][Hide abstract] ABSTRACT: Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.
Diseases of the Colon & Rectum 04/2005; 48(3):575-81. DOI:10.1007/s10350-004-0809-3 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Polyethylene glycol 3350 increases stool frequency and accelerates colonic transit. Used as a laxative, it proved effective in patients with normal and slow transit. Although free of severe side effects, it may cause nausea and vomiting. The effect of this substance on upper gut transit has not been studied.
To investigate the effect of polyethylene glycol 3350 on gastric emptying and oro-caecal transit in 12 healthy subjects.
In a randomised controlled study, isosmotic polyethylene glycol 3350 electrolyte balanced solution, in the maximal recommended dose or isosmotic electrolyte solution, was administered after breakfast and lunch on separate days. Gastric half-emptying time and oro-caecal transit time were measured using [13C]-octanoate and lactose-[13C] ureide breath tests.
Isosmotic polyethylene glycol 3350 electrolyte solution, as compared to isosmotic electrolyte solution, decreased oro-caecal transit time from 424+/-28 to 314+/-17 min (P = 0.001). Gastric half-emptying time was significantly increased (84+/-6 min versus 127+/-14 min; P = 0.006).
Polyethylene glycol 3350 accelerate oro-caecal transit in healthy subjects, but also cause an important delay in gastric emptying. The delay in gastric emptying may be of clinical significance in patients who have associated gastroparesis.