Dr James Marion Sims – kontrowersyjny „ojciec ginekologii”

Vesico-vaginal fistula (VVF) was a a catastrophic and common complication of childbirth among American women. In the mid 1800s Dr. J. Marion Sims reported the successful repair of vesicovaginal fistulas with a technique he developed by performing multiple operations on on a group of young, enslaved, African American women who had this condition between 1846 and 1849. Numerous modern authors have attacked Sims’s medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women. It is impossible to understand Sims’s operations within the clinical context of the 1840s. To avoid the problems of “presentism”, in which beliefs, attitudes, and practices of the 21st century are anachronistically projected backward into the early 19th century we have to judge Sims within the context of his time. This is the only way to understand that Sims’ first fistula operations were legal, that they were carried out with express therapeutic intent for the purpose of repairing these women’s injuries, that they conformed to the ethical requirements of his time, and that they were performed with the patients’ knowledge, cooperation, assent, and assistance. Though the legacy of Dr. Sims is for some authors controversial he still seems to be considered as “the father of gyncology” who developed the first consistently successful surgical technique for the vesico-vaginal fistula.

Assessment of the rationale for the use of preventive antibiotic (clindamycin) therapy in patients operated on for anal fistula based on authors’ own experience

Introduction. Bacterial infection of the anal glands has been considered the main cause of anal fistulae for many years. Other most common causes include Crohn’s disease, ulcerative colitis, any type of immunosuppression (e.g. HIV infection, immunosuppressants), foreign bodies, and injuries. Studies assessing the type of bacterial pathogen involved in the formation of an anal fistula are sparse. Furthermore, it seems that although surgery remains the primary treatment of the disease, the importance of treating cryptic infection and the use of antibiotic therapy based on culture findings seems underestimated. Aim. The aim of this study was to assess the rationale for the use of preventive antibiotic therapy in patients after proctological surgeries. Material and methods. In the period from January 1 to December 31, 2019, 46 patients (40 men, 6 women) aged 28 to 71 years (mean age 49 years) were operated on at the Department of General Surgery of the County Hospital in Ostrów Mazowiecka for anal fistulae. All patients were operated on by the same surgeon experienced in proctological surgery. Bacterial cultures were collected intraoperatively and preventive antibiotic therapy in the form of IV clindamycin 2 × 600 mg was used in all patients. Results. A large number of Bacteroides spp. showed high resistance (88%) to clindamycin. Anaerobic bacteria showed 60% resistance to clindamycin. Conclusions. 1. Clindamycin should not be used in preventive antimicrobial treatment in patients undergoing surgical treatment for anal fistula in the Department of General Surgery of the County Hospital in Ostrów Mazowiecka. 2. The variable sensitivity of bacteria to antimicrobials should be considered and antibiotic prophylaxis should be changed depending on the resistance developed to the subsequent antibiotics used.

Outcomes of treatment of haemorrhoidal disease with KLS Martin maXium marClamp® CUT IQ thermal tissue fusion instrument based on offset electrode technology compared to the Milligan-Morgan procedure with bipolar coagulation for the excision of grade III and IV haemorrhoids

Introduction. The study compared the effects of surgical treatment of grade III and IV haemorrhoids achieved with a conventional operative technique and by using a thermal tissue fusion instrument based on offset electrode technology. A total of 60 patients with grade III and IV haemorrhoids were operated on in the Department of General and Oncologic Surgery, Municipal Hospital in Siemianowice Śląskie, and in the On-Clinic Medical Centre in Chorzów, between October 2011 and September 2015. Aim. The aim of the study was to compare the outcomes of treatment of haemorrhoidal disease using KLS Martin maXium marClamp® CUT IQ thermal tissue fusion instrument based on offset electrode technology and the Milligan-Morgan surgical procedure with bipolar coagulation for the excision of grade III and IV haemorrhoids. Material and methods. The patients were divided into two groups: Group 1 – patients operated on using KLS Martin maXium marClamp® CUT IQ thermal tissue fusion instrument based on offset electrode technology. Group 2 – patients operated on using the conventional Milligan-Morgan technique with electrocoagulation. The evaluated parameters included the length of hospital stay after surgery, duration of the surgical procedure, level of pain on the postoperative days 1 and 2 rated on a 10-point VAS scale, and postoperative wound healing time. Results. A reduction in postoperative pain, shorter procedure duration and hospital stay, and more rapid postoperative wound healing were observed in Group 1 compared to Group 2. Conclusions. In our study material, the application of a thermal tissue fusion instrument using offset electrode technology in surgeries to remove grade III and IV haemorrhoids, compared to the conventional Milligan-Morgan procedure with electrocoagulation, brought the following results: – less postoperative pain, – shorter duration of surgical procedure, – reduced length of hospital stay, – faster healing of postoperative wound.

Undifferentiated cancer with unknown primary location infiltrating the rectum – a case report

Colorectal cancer (CRC) is the third leading malignancy in men after prostate and lung cancer. Adenocarcinomas account for about 90% of all colorectal cancer cases. Carcinomas of unknown primary site (CUPs) are usually found in patients > 60 years of age. They account for 3% of all malignancies in Poland. We describe a diagnostically challenging case of undifferentiated carcinoma of unknown primary site invading the rectum. Rectal specimens collected during endoscopy and open biopsy, as well as samples collected during laparotomy from the side of the peritoneal cavity did not confirm cancer despite progressing clinical symptoms of an ongoing neoplastic process. Histopathological diagnosis was obtained only with core-needle biopsy of the rectal infiltration and sphincter muscles. The histopathological confirmation of carcinoma invading the sigmoid colon, rectum, anus and the mesorectum described in PET-CT enabled patient qualification for further palliative treatment.

Reconstruction of anal sphincter muscles in post-traumatic sphincter damage with fecal incontinence – case report

Extra-obstetric injuries to the anal area are rare. The cause of isolated damage is most often accidents when working with utility machines or impalement injuries caused by sharp objects, as well as transport accidents. The authors present a rare case of a young man who, 8 years ago, suffered an extensive pelvic fracture injury, with rectal detachment, and extensive injuries to the thigh and buttock area with skin-fat lobe detachment in the course of a transport accident. At the pediatric surgery center, fracture stabilization was performed and colostomy was created, which was closed when patient completed 15 years of age. Due to persistent symptoms of fecal incontinence, the man was qualified for a late reconstruction of sphincters. Prior to the operation, detailed imaging diagnostics were performed. 6 months after the procedure, the patient declared significant improvements in quality of life and fecal retention (3/20 points on the Wexner Faecal Incontinence Quality of Life Scale). After complete healing of the wound, the patient was prescribed sphincter electrostimulation. The authors conclude that there are no clear guidelines for the management of patients with rectal and anal injuries. Treatment should be individualized on a case-by-case basis. In the situation of supplying the acute damage to the sphincter apparatus, it is crucial to verify that the injury does not also include the intraperitoneal organs, as this determines further proceedings and a possibility of primary definitive reconstructive surgery. For the successful functionality of sphincters, it is also important to implement muscle-strengthening exercises, “biofeedback” therapy and electrostimulation.

Proctogyneacology – who should treat? A proposed treatment algorithm

Proctogyneacology deals with conditions involving the anal canal, anal sphincter muscles, rectum, rectovaginal septum, and the female reproductive tract. They may be due to sagging of the pelvic floor and the rectovaginal septum (rectal, vaginal or uterine prolapse, enterocele and rectocele), perinatal injury, including sphincter damage, rectovaginal fistulas, endometriosis with anal sphincter and rectovaginal septum involvement, proctological inflammatory diseases in pregnancy, as well as radiation-induced rectal damage after gynaecological cancer treatment. There are no set guidelines defining which specialist should operate on these patients. We attempted to systematise this issue in the form of an algorithm. An interdisciplinary dialogue allowing for our professional development and, most of all, therapeutic success and reduced risk of postoperative complications, seems to be crucial.

Proctology – an overview of new reports

Every year, reports are published in medical journals to present new developments in the treatment of proctological diseases or related problems. The authors of this paper have reviewed the literature in the field of proctology spanning the last few years. A few publications have been selected and presented together with the authors’ practice-oriented comments. Research papers published in highly indexed scientific journals are subject to rigorous evaluation and review criteria, which makes them very credible. Nevertheless, there are often conflicting reports on similar or even the same surgical or pharmaceutical therapies. Time and clinical practice verify the value of these studies. The authors discuss reports on the application of chemical seton in the treatment of anal fistulas, FiXcision method in fistulectomy, outline contraindications to performing the LIFT procedure, and present the latest developments in stem cell therapy for fistulas and Botox treatment of anal fissures, as well as the application of new tools in proctological surgery. It is concluded that incorporating novel solutions into one’s own professional practice must be done with a certain amount of reserve, as their value is ultimately verified by time and distant outcomes of treatment.

Laser hemorrhoidoplasty (LHP) using a 1470 nm radial fibre laser – early efficacy assessment based on own data

Introduction. Haemorrhoidal disease is one of the most common colorectal conditions. Although many treatment methods have been developed, Milligan-Morgan hemorrhoidectomy remains the most widely practised surgical technique. Aim. The aim of this study was to compare the effectiveness of Milligan-Morgan hemorrhoidectomy and laser hemorrhoidoplasty using a 1470 nm radial fibre laser. The following variables were analysed: procedure duration, length of procedure-related hospital stay, postoperative pain, and time to return to normal daily activities. Material and methods. The study group included 178 patients (women 45%, men 55%), including 82 patients undergoing laser hemorrhoidoplasty and 96 patients undergoing Milligan-Morgan hemorrhoidectomy. The mean age of the patients was 50 years, with the youngest patient aged 19 years and the oldest patient aged 65 years. The mean age of patients was lower in the laser hemorrhoidoplasty group (54.23 vs 45.15 years). The mean follow-up was 14 months (3-35 years). Results. The mean duration of laser hemorrhoidoplasty was shorter than that of Milligan-Morgan hemorrhoidectomy (13.9 vs. 22.3 min). There was no need for a revision surgery after laser hemorrhoidoplasty, whereas reoperation was necessary in three cases after classical hemorrhoidectomy. The mean and the shortest time of return to work was 14 and 5 days for laser hemorrhoidoplasty compared to 21 and 15 days for classical hemorrhoidectomy, respectively. Opioid analgesics were needed in 51% of patients after Milligan-Morgan hemorrhoidectomy and none of the patients after laser hemorrhoidoplasty. Conclusions. Laser hemorrhoidoplasty is an effective treatment approach in grade II-IV haemorrhoidal disease. It is associated with less pain compared to conventional hemorrhoidectomy. The duration of both the procedure itself and hospital stay is shorter after laser hemorrhoidoplasty compared to Milligan-Morgan hemorrhoidectomy. The return to normal daily activities is also faster in the first case.

Amina Okujewa (1983-2017) – chirurżka na wojnie XXI wieku. In memoriam

Amina Viktorivna Okueva (Ukrainian: ????? ?????????? ??????); was a Ukrainian doctor of Chechen descent, During the Euromaidan she worked as a medic in the Kyiv-2 battalion and saw combat in the city of Debaltseve after it was taken over by Russian-aligned rebels in 2015. She was killed in an ambush by unknown attackers on 30 October 2017. Her husband Adam Osmaev, a leader of the Dzhokhar Dudayev Battalion. Okueva was killed in a military-style ambush on 30 October 2017 near the village of Hlevakha, Kyiv Oblast. Unidentified attackers opened fire on the car containing her and her husband while it slowed by a railroad crossing, firing five rounds into her including two fatal rounds into her head. Adam Osmaev was injured in the ambush but survived.