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Tomasz Kościński

Treatment of Iatrogenic Anal Stricture

Anal stenosis is an abnormal narrowing deformation of the anal canal. The anal canal become unable to extend during defecation, due to tissue cicatrization and loss of elasticity

The aim of the study. 1. Careful selection of different anoplasty techniques according to the size and shape of the stenosis. 2. Describing the results of anoplasty operations after 3 months.

Material and methods. The study includes 7 patients operated on for critical anal stricture during a 10-year period, with ages ranging from 22 to 76. Anal stenoses were complications of prior anorectal surgery. Seven reconstructive operations were performed. Five conservative excisions of scar tissue using the Y-V anoplasty for covering the tissue defect. In one case of cicatrization after improperly performed Whitehead hemorrhoidectomy, two S-shaped rotational flaps were used. Another patient was treated by radial incision of the stricture and internal sphincterotomy.

Results. In all but one patient, durable anal dilatation was achieved. One patient developed late recurrent anal stricture. She was successfully reoperated after 6 years using internal sphincterotomy and a mucosal advancement flap.

Conclusions. Various surgical techniques, such as the incision of the scar and internal anal sphincter, removal of scar tissue and covering the defects with well vascularized skin flaps, are available for management of anal stenosis. Early complications like visible wound dehiscence in the donor site or translocated flaps and local infection may occur. In most cases, they are amenable to medical management and do not affect functional results.

Open access

Tomasz Kościński and Honorata Stadnik

Surgical Treatment of Rectocele as the Most Common Cause of Rectal Voiding Disturbances. Own Experience with the Use of Prosthetic Material

The aim of the study was to present different methods of reconstruction in case of rectovaginal septum defects, considering female patients with impaired colorectal voiding.

Material and methods. During the period between 2001 and 2010, 39 female patients, aged between 42 and 75 years (mean age-58 years) were subject to surgical intervention. Patients complained of voiding disturbances, sensation of a "mass" in the pelvis (64.1%), dyspareunia (30.8%), anal sphincter insufficiency (17.9%) and urinary incontinence (10.3%).

Defecography and MRI examinations confirmed rectocele (100%), enterocele (46.6%), pelvic floor prolapse (35.9%), vaginal prolapse (30.8%), and rectal prolapse (25.6%).

Considering the surgical treatment of rectocele the following prosthetic material was used: polypropylene mesh and collagen implants (Pelvicol ®). In case of 19 patients with low rectocele the transvaginal approach was used. In case of high rectocele and coexisting pelvic organ prolapse the mesh was implanted by means of laparotomy (12 pts) or the abdomino-vaginal approach (8 pts).

Results. Permanent reconstruction of the rectovaginal septum and withdrawal of voiding disturbances was observed in all patients operated by means of the transvaginal approach. Dyschesia symptoms were present in 16.6% of patients after mesh implantation by means of laparotomy, and in 12.5% of patients after the abdomino-vaginal approach. 10.3% of patients complained of pelvic pain and rectal tenesmus. All the above-mentioned symptoms were observed after polypropylene mesh implantation. The percentage of reoperations, due to complications amounted to 17.9%. Insignificant erosion of the prosthetic material was diagnosed in 7.7% of patients. 94.6% of patients were satisfied with the proposed treatment.

Conclusions. The use of prosthetic material in the treatment of pelvic floor anatomical defects is an effective and safe method, considering patients with colorectal voiding disturbances.

Open access

Tomasz Kościński and Honorata Stadnik

The Effect of Surgical Treatment on Anal Sphincter Function in Patients with Rectal Prolapse

The aim of the study was analysis of an anal sphincter function in patients before and after surgery for rectal prolapse.

Material and methods. Between 1987 and 2005, 49 patients underwent operations for rectal prolapse. The anal sphincter function was analyzed in 17 of these patients. Abdominal approach surgery was performed in 13 patients; this involved rectopexy in 11 and sigmorectal resection in two others. A transanal approach was chosen in four patients, with the Mikulicz technique in two cases, the Delorme procedure in one, and the Altmeier procedure in the remaining case.

Results. In all patients who were operated using the transanal approach, we observed some regression in anal sphincter insufficiency. Among the patients operated using the abdominal approach, first degree incontinence persisted in three cases, second degree in five cases, and third degree persisted in four cases. As a result of the surgical treatment of rectal prolapse by rectopexy and transanal approach, we observed a statistically significant increase in the resting anal sphincter pressure; this increase on average reached 58.8 mm Hg. A statistically significant increase in the average maximum squeeze anal sphincter pressure (95.9 mm Hg) was attained after the surgical procedures were performed on patients with rectal prolapse.

Conclusion. The results suggest that the improvement of anal function in the control of stool and flatus after surgical treatment for rectal prolapse appears to be the result of an increase in the rest and maximal squeeze pressures of the anal sphincters.

Open access

Tomasz Kościński and Marta Sękowska

Surgical Treatment of Rectovaginal Fistulas

Rectovaginal fistulas account for less than 5% of all anorectal fistulas. They may occur as a result of obstetrical injuries, inflammatory bowel diseases, or pelvic cancer irradiation.

The aim of the study was to describe the results of different methods of surgical treatment according to the etiology and localization of rectovaginal fistulas.

Material and methods. The study included 23 female patients who underwent operations for rectovaginal fistulas within the period of 1995 to 2006. The age of patients ranged from 18 to 64 years, with an average age of 41 years.

14 patients received radical treatment according to the etiology and localization of the fistulas: four were treated with abdominal approach, six with a local excision of the rectovaginal fistula involving layer closure of rectal and vaginal openings and interposition of musculomucosal flaps, and four with a simple fistulectomy involving the removal of inflamed tissue and the reconstruction of the perineal body, anal sphincters, and all layers of the rectal and vaginal walls.

In nine cases, patients received a palliative surgical treatment to address extensive tissue destruction resulting from radiotherapy for uterine cervix cancer or advanced rectal cancer.

Results. Complete recovery occurred in patients who underwent laparotomy for rectovaginal fistulas following inflammatory bowel disease or complicating anterior resection of the rectum. Patients operated on using rectal and vaginal approaches displayed positive results, as did those who underwent. fistulectomy with perineal body and anal sphincter reconstruction.

Conclusions. Various surgical techniques are available for the management of rectovaginal fistulas depending on their etiology, size, and location. The best results of low rectovaginal fistula treatment occurred using fistulectomy with layer closure and both-sided covering of the tissue defect with advancement vaginal and rectal flaps.

Open access

Tomasz Kościński, Wiktor Meissner and Honorata Stadnik

Abdominal Rectopexy with Absorbable and Non-Absorbable Materials in the Treatment for Rectal Prolapse

The aim of the study was to present and compare own results of abdominal rectopexy performed with absorbable and nonabsorbable materials used in surgical repair of rectal prolapse.

Material and methods. In the years 1991-2009, 50 patients were operated on for rectal prolapse. The first 8 patients (group I) were operated using absorbale polyglycolic acid mesh. The next 42 patients were operated using non-absorbable polypropylene mesh (group II). 12 patients with chronic, incurable constipation had sigmoidectomy and rectopexy performed at the same operation. Rectopexy was performed with the mesh and fixed to the pelvic fascia and periosteum and mesorectum, leaving the anterior one third of the rectum free. 6 months after surgery functional outcomes were evaluated. Statistic analysis with the level of statistical significance p<0,005 was applied to obtained functional results.

Results. On the follow up visits, there were no symptoms of the recurrence of rectal prolapse in 5 patients (62.5%) from group I and in 25 patients (92.6%) from group II. Patients relapsing were reoperated 24 to 98 months after primary surgery. In all patients from group I (absorbable mesh), prosthetic material was not found at reoperation. In redo surgery only non-absorbable mesh was used.

Conclusions. The effectiveness of rectal fixation depends on the on the durability of the prosthetic material. In the studied group polypropylene mesh was superior in rectopexy to absorbable mesh.

Open access

Marta Sękowska, Tomasz Kościński, Tomasz Wierzbicki, Jacek Hermann and Michał Drews

Treatment of the Hemorrhoids and Anal Mucosal Prolapse Using Elastic Band Ligature - Early and Long Term Results

The aim of the study was to evaluate the results of the treatment of internal hemorrhoids and anal mucosal prolapse using elastic band ligation and to compare this method to chosen surgical procedures.

Material and methods. The study included 648 patients (363 males and 285 females). 474 patients were treated using an elastic band ligature and 174 patients underwent surgical hemorrhoidectomy. The average age of the patients in both groups was similar - 49 years.

The treatment tolerance was evaluated in the prospective study group. The intensity and duration of pain was assessed on the first and second postoperative day using a Verbal Rating Scale.

Results. 86.5% of the patients were cured using Barron's procedure, success rate for second-degree hemorrhoids was 89% and for third degree - 85.2%. Surgical hemorrhoidectomy was effective in 92% of patients. Early failure of elastic ligature was noted in 2.5% of patients. The recurrences of hemorrhoidal symptoms were observed in 11% of Barron's group and in 8% after hemorrhoidectomy. The intensity of pain was much higher among patients after surgical hemorrhoidectomy. The average of the pain score in the 4th hour was 0.3 for the elastic band ligation and 1.4 for the surgical treatment. In the 24th hour - 0.2 and 1.7 respectively. Mean postoperative stay was 3.8 days.

Conclusions. Rubber band ligation is highly effective and well tolerated. Relatively minor pain following this procedure is found in only 9.5% of patients. The disadvantages of surgical hemorrhoidectomy are: important postoperative pain and long time of wound healing that impair the recovery to professional activity.

Open access

Adam Bobkiewicz, łukasz Krokowicz, Tomasz Banasiewicz, Tomasz Kościński, Maciej Borejsza-Wysocki, Witold Ledwosiński and Michał Drews


Iatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased.

The aim of the study was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014.

Material and methods. In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay.

Results. 82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%).

Conclusions. The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented.

Open access

Andrzej Ratajczak, Tomasz Kościński, Tomasz Banasiewicz, Małgorzata Lange-Ratajczak, Jacek Hermann, Adam Bobkiewicz and Michał Drews

Mesh biomaterials have become the standard in the treatment of hernias, regardless the location. In addition to the obvious advantages of the methods based on implantable biomaterials, one should be aware of the possible complications, such as their migration to the abdominal organs.

Material and methods. The study group comprised patients operated at the Department of General, Gastroenterological Oncology, and Plastic Surgery during the period between 2008 and 2011, due to hernia surgery with mesh implantation. We also analysed the number of patients operated, due to complications of mesh migration during the same period.

Results. 368 patients were subject to mesh implantation, due to hernias during the period between 2008 and 2011. Three patients underwent surgery because of symptomatic migration of the mesh (ileus, fistula).

Conclusions. The frequency of mesh migration is difficult to determine because of the different criteria of migration, observation period, and other factors. In patients after mesh implantation the potential migration of the biomaterial should be considered in case of unclear or acute abdominal symptoms.