This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures. [ citation needed ]  During the procedure the external anal sphincter muscle is pulled in when the anal cushion is cut followed tight stapling with 2 rows of 28 staples so if external hemorrhoids are present they also get pulled in and get hidden inside and get tucked inside the anal canal and reappear when the staples fall after a few months when the external anal sphincter comes to its normal position.


Previously a lot of surgeons thought that this procedure is for external hemorrhoids also as they disappear but instead they are hidden inside and fool the eye and reappear after the staples fall off. [ citation needed ]


Hemorrhoids  are amongst the most common anal disorders. Patients may complain of bleeding,  prolapse , personal discomfort and minor  anal leakage . Where traditional non-surgical measures such as rest, suppositories and dietary advice fail to improve the condition, there is then a choice of further treatments. Opinion on the best management for patients varies considerably. While many treatments for hemorrhoids may be performed without  anesthetics , the lasting effect of these conservative therapies has been questioned. Many patients treated with  rubber band ligation  or injection  sclerotherapy  require multiple treatments and there is high recurrence rate following these procedures.


Conventional hemorrhoidectomy provides permanent symptomatic relief for most patients, and effectively treats any external component of the hemorrhoids. However, the wounds created by the surgery are usually associated with considerable post-operative pain which necessitates a prolonged recovery period.  This can put a stress on a  general practitioner ’s resources, may alienate the patient and delays the patient's return to a full, normal lifestyle and the workplace. Because of this, surgeons will generally reserve formal  excision  for the most severe cases of prolapse, or for patients who have failed to respond to conventional treatments. [ medical citation needed ]


Obstructed defecation  syndrome (ODS) can be caused by structural deformities in the rectum resulting in chronic constipation. STARR can treat ODS using minimally invasive methods. STARR is a surgical procedure developed by Antonio Longo, an Italian surgeon, that is performed through the anus, requires no external incisions, and leaves no visible scars. Using a surgical stapler, the procedure removes the excess tissue in the rectum, reducing the anatomical defects that can cause ODS.


In a study of 90 patients undergoing the STARR procedure, patients were hospitalized one to three days, experienced minimal postoperative pain after the procedure, and resumed employment or normal activity in 6 to 15 days. In this study, most ODS patients experienced a significant improvement in their ODS symptoms following STARR.  [ citation needed ]


PPH uses a circular stapler to reduce the degree of prolapse. The procedure avoids the need for wounds in the sensitive perianal area thus reducing post-operative pain considerably, and facilitates a speedier return to normal activities. This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures.
 [ 2 ] [ 3 ] [ 4 ]


This procedure was first described by an Italian surgeon – Dr.  Antonio Longo , Department of Surgery, University of Palermo – in 1993 and since then has been widely adopted through Europe. This procedure avoids the need for wounds in the sensitive perianal area and, as a result, has the advantage of significantly reducing the patient's post operative pain. [ 2 ] [ 3 ] [ 4 ]  Follow-up on relief of symptoms indicate a similar success rate to that achieved by conventional haemorrhoidectomy. [ 2 ] [ 5 ]  Since PPH was first introduced it has been the subject of numerous clinical trials and in 2003 the National Institute of Clinical Evidence (NICE) in the UK issued full guidance on the procedure stating it was  safe and efficacious .


PPH is generally indicated for the more severe cases of internal hemorrhoidal prolapse (3rd and 4th degree) where surgery would normally be indicated. It may also be indicated for patients with minor degree haemorrhoids who have failed to respond to conservative treatments.  The procedure may be contra-indicated when only one cushion is prolapsed or in severe cases of fibrotic piles which cannot be physically repositioned.


In addition to correcting the symptoms associated with the prolapse, problems with bleeding from the piles are also resolved by this excision.  Although the cushions may be totally or partially preserved, the blood supply is interrupted or venous drainage is improved by the repositioning.  Any external component which remains will usually regress over a period of 3–6 months.  Prominent skin tags may, on occasion, be removed during the operation but this may increase the postoperative pain so is not routinely performed.


PPH employs a unique circular stapler which reduces the degree of prolapse by excising a circumferential strip of mucosa from the proximal anal canal.  This has the effect of pulling the hemorrhoidal cushions back up into their normal anatomical position.
Usually, the patient will be under general anesthetic, but only for 20–30 minutes.  Many cases have been successfully performed under local or regional anesthesia and the procedure is suited to day case treatment.  [ citation needed ]


Due to the low level of post-operative pain and reduced analgesic use, patients will usually be discharged either the same day or on the day following surgery. Most patients can resume normal activities after a few days when they should be fit for work.  The first bowel motion is usually on day two and should not cause any great discomfort.  Staples may be passed from time to time during defecation.  This is normal and should not be a cause for concern. [ medical citation needed ]


Since 2002 more than 100 articles have been published reporting complications during and after stapled hemorrhoidectomy.


Bleeding is the most common postoperative complication. Severe postoperative pain could be caused by dehiscence of the anastomosis or due to the fact that the anastomosis is too near to the linea dentata. [ citation needed ]  A rare complication stemming from PPH is intra- abdominal  bleeding. [ 6 ]


Many long-term complications have been described. Most of them are related to either an incorrect indication for surgery or technical errors. Several authors stated that although it seems to be an easy operation to perform, it should only be done by experienced surgeons. Severe complications leading to death have been described but are rare. Irreversible urge incontinence due to lesions of the sphincter muscle or a diminished rectal capacity due to resection of too much mucosa, are quite common complications if the procedure is not performed properly. Rectovaginal fistulas and anastomotic diverticula are very rare but possible.


Steatorrhea  (or  steatorrhoea ) is the presence of excess  fat  in  feces . Stools may be bulky and difficult to flush, have a pale and oily appearance, and can be especially foul-smelling. [ 1 ]  An oily anal leakage or some level of  fecal incontinence  may occur. There is increased fat excretion, which can be measured by determining the fecal fat level. [ 2 ]


Impaired digestion or absorption can result in fatty stools.
Possible causes include  exocrine pancreatic insufficiency , with poor digestion from lack of  lipases , loss of  bile salts , which reduces  micelle  formation, and small intestinal disease-producing  malabsorption . Various other causes include certain medicines that block fat absorption or indigestible or excess oil/fat in diet. [ 2 ]


The absence of  bile  secretion can cause the feces to turn gray or pale. Bile is responsible for the brownish color of feces. In addition to this, bile also plays a role in fat absorption, where dietary lipids are combined so that pancreatic lipases can hydrolyze them before going towards the small intestine. Without bile acids, this pathway would have a hard time occurring, which would lead to fat malabsorption and make steatorrhea more probable to occur. [ 2 ]  Other features of fat malabsorption may also occur such as reduced bone density, difficulty with vision under low light levels, bleeding, bruising, and slow blood clotting times. [ 1 ]


Orlistat  (also known by trade names Xenical and Alli) is a diet pill that works by blocking  the enzymes that digest fat . As a result, some fat cannot be absorbed from the gut and is excreted in the feces instead of being metabolically digested and absorbed, sometimes causing oily anal leakage. [ 6 ] [ 7 ] [ 8 ]  Vytorin (ezetimibe/simvastatin) tablets can cause steatorrhea in some people. [ 6 ] [ 8 ]


Some studies have shown that stool lipids are increased when whole nuts are eaten, compared to nut butters, oils or flour [ 9 ]  and that lipids from whole nuts are significantly less well absorbed. [ 10 ]


Consuming  jojoba oil  has been documented to cause steatorrhea and anal leakage because it is indigestible. [ 11 ]


Consuming  escolar  and  oilfish  (sometimes mislabelled as  butterfish ) will often cause steatorrhea, also referred to as gempylotoxism or gempylid fish poisoning or  keriorrhea . [ 12 ]


The fat substitute  Olestra , used to reduce digestible fat in some foods, was reported to cause leakage in some consumers during the test-marketing phase. As a result, the product was reformulated before general release to a hydrogenated form that is not liquid at physiologic temperature. The U.S.  Food and Drug Administration  warning indicated excessive consumption of Olestra could result in "loose stools"; however, this warning has not been required since 2003. [ 7 ] [ 13 ]


Steatorrhea should be suspected when the stools are bulky, floating and foul-smelling. [ 1 ]    Specific tests are needed to confirm that these properties are in fact due to excessive levels of fat.  Fats in feces can be measured over a defined time (often five days). [ 14 ]  Other tests include the (13)C-mixed triglycerides test and fecal  elastase , to detect possible fat maldigestion due to  exocrine pancreatic insufficiency , [ 14 ]  or various specific tests to detect other causes of  malabsorption  such as  celiac disease . [ 15 ]


Treatments are mainly correction of the underlying cause, as well as digestive enzyme supplements. [ 2 ]


In  fecal incontinence  (FI), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. There are many surgical options described for FI, and they can be considered in 4 general groups. [ 1 ]


The relative effectiveness of surgical options for treating fecal incontinence is not known. [ 2 ]  A combination of different surgical and non-surgical therapies may be optimal. [ 2 ]  A surgical treatment algorithm has been proposed for FI, [ 3 ]  although this did not appear to include some surgical options. Isolated sphincter defects may be initially treated with sphincteroplasty and if this fails, the patient can be assessed for sacral nerve stimulation. Functional deficits of the external anal sphincter (EAS) and/or internal anal sphincter (IAS), i.e. where there is no structural defect, or only limited EAS structural defect, or with neurogenic incontinence, may be assessed for sacral nerve stimulation. If this fails, neosphincter with either dynamic graciloplasty or artificial anal sphincter may be indicated. Substantial muscular and/or neural defects may be treated with neosphincter initially.


This operation aims to repair sphincter defects (which may be of unknown cause) or damage from trauma (usually caused by obstetric damage). Where the sphincter has separated from a tear, this procedure brings these ends back together. Primary sphincteroplasty is repair carried out soon after the trauma has occurred, whilst other repairs may be carried out years after the original trauma (secondary or delayed sphincter repair), usually because the trauma went unrecognised. Usually, sphincter defects are in the anterior position on the sphincter, when an anterior sphincteroplasty may be carried out. Where the sphincter defect is laterally or posteriorly placed, this carries a less successful outcome. [ 3 ] [ 4 ] [ 5 ]  Overlapping anterior sphincteroplasty is preceded by a bowel preparation and possibly antibiotics. Once the patient is under anesthesia, an incision is made in front of the anus (the anterior perineum). Scar tissue is removed and the mucosa of the anal canal separated from the damaged sphincter. The sphincter is cut and its ends overlapped and then stitched back together. The exact method of the procedure varies, e.g. the cut sphincter may be stitched back end to end, rather than overlapped, or the IAS and EAS may be repaired as separate stages. Sphincter repair may sometimes be combined with an anterior levatorplasty (an operation to tighten the pelvic floor). A surgical drain is left to prevent buildup of fluid. After the operation,  sitz baths  are recommended to maintain hygiene during healing, and laxatives prescribed to avoid hard stool. [ 5 ]  Overlapping anterior sphincteroplasty improves FI symptoms in the short term in most (50-80%) patients with sphincter defects. Thereafter, continence deteriorates. Most who undergo this operation are incontinent again after 5 years. Poor results with this procedure may be related to pelvic floor denervation (nerve damage). Primary sphincter repair is inadequate in most women with obstetric ruptures following vaginal delivery. Residual sphincter defects remain in most and around 50% remain incontinent. If there is a residual sphincter defect following the operation (as demonstrated by endoanal ultrasonography), then the procedure may be repeated. [ 4 ] [ 5 ]


This procedure aims to improve FI by restoring the anorectal angle and lengthen the anal canal.  The main indication is denervation of the pelvic floor (e.g. descending perineum syndrome). After the patient is anesthetized, an incision is made posterior to (behind) the anus and a space between the EAS and IAS is opened up. This plane is followed, freeing the rectum from its attachment to the pelvic floor. Puborectalis and pubococcygeus are folded and held with stitches. These folds will lengthen the anal canal. It is safe and simple, but long term improvements in FI are poor (30-40%). Total pelvic floor repair refers to a procedure combining postanal and anterior anal repair. [ 5 ]


These procedures aim to inject  bio-compatible  material into the walls of the anal canal, aiming to bulk out these tissues. This may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and thereby reducing FI. Originally, this technique was described for urinary incontinence, but was first used for FI in 1993, [ 6 ]  especially passive soiling due to IAS dysfunction. The procedure can be carried out under  local anesthetic  on an  out patient  basis, or with  caudal epidural anesthesia , [ 7 ]  or with  intravenous sedation , or under  general anesthesia . [ 8 ]  This measure has many advantages over more invasive surgery, since there are rarely any serious complications. [ 8 ]  Many different materials have been used as perianal injectable bulking agents. [ 9 ]  Of the available materials, which one is the best is not known. [ 7 ]


In 2013 a  Cochrane  systematic review included 5 randomized trials, which in total was 382 patients. None of the included studies reported long term follow up after 3, 6 or 12 months post procedure. [ 9 ]  In another review of 889 patients across 23 studies, a pooled improvement rate in measures of incontinence was 39.5%. [ 8 ]  In some cases there is no improvement after the procedure, and the injections are repeated in up to 34% of cases. [ 8 ]  There can also be worsening of symptoms after an initial improvement period. [ 8 ]  In one randomized control trial, the placebo treatment gave over 30% improvement in symptoms, suggesting that patient psychology (i.e. the  placebo effect ) may be in part responsible for any positive results. [ 10 ]  One author criticized these procedures, stating that simply narrowing the anal canal was an instinctive and naive solution which does not consider the complex pathopysiological mechanisms of FI. [ 10 ]  Concerns have been raised about migration of the particles (in the case of Durasphere) away from the site of injection, or the total resorption of the material (in the case of hyaluronic acid and hydroxyl coaptite). [ 10 ]  Most research suggests that the positive effects of most of the bulking agents seem to reduce after 6 to 12 months. [ 7 ]  At 6 months the material has been reported as missing or migrated in 18.4% of cases, at 3 years or more in 20.2% of cases. [ 8 ]  One author drew attention to the fact that all existing research on these procedures was driven by the companies who also marketed the treatments, and therefore the studies are at high risk of bias. [ 10 ]


Mesenchymal stem cells  (MSC) and  muscle-derived stem cells  (MDSC) have been used in urology to treat urinary incontinence.  Fibroblasts  in a collagen carrier were injected into the submucosa of the urethra, and  myoblasts  were injected into the urethral sphincter. The procedure was reported as being successful in most cases. [ 11 ]  Injection of MSCs may lead to engrafting and forming multinucleated myotubes, which helps to regeneration after injury. [ 12 ]  In theory, use of stem cells removes the problems of reabsorption and migration of the bulking material. [ 11 ]  There is similar research which aims to regenerate muscles and repair tissues by  cell therapy  to treat injuries of the external anal sphincter. [ 9 ]


The "Gatekeeper" and "SphinKeeper" are self-expandable prostheses which are implanted into the intersphincteric space of the anal canal. [ 7 ]


Sacral nerve stimulation  was originally used in urinary incontinence. It was first used to treat FI in 1995. The procedure involves implantation of an electrical device (an implanted pulse generator, IPG) which applies a low amplitude electric current to a  sacral  nerve (usually  S3 ). This appears to modulate the nerves and muscles of the pelvic floor and rectum. A  Cochrane  review of the efficacy of sacral nerve stimulation concluded that more research was needed, but can be helpful in selected people with FI, and reduce symptoms in selected people with constipation. [ 13 ]  It is possible to simulate the effect of SNS without surgery. This is trial usually lasts around 2–3 weeks, where a temporary percutaneous peripheral nerve electrode is placed in the lower back, and then connected to an external stimulator. This trial may not always accurately predict a successful outcome. If there is an improvement, a permanent electrode can be implanted on the sacrum and connected to an stimulator which is in turn implanted in the lower abdominal wall or in the buttock. Implanted stimulators usually last 8 years. The patients who may benefit from SNS include those with intact anal sphincters and those with a history of unsuccessful anal repair. [ 5 ]  Complications of the surgery are rare, including pain and infection, which may require implant removal in 5% of cases. The effects of SNS may include increased resting and squeeze anal tone, and improved rectal sensitivity. There is reported reduction of involuntary loss of bowel contents and increased ability to postpone defecation. A substantial percentage of patients regain full continence. Patient quality of life has also been shown to be improved after the procedure. [ 3 ]


In the 1950s described an operation using the  gracilis muscle  from the inner thigh and wrapping it around the anus to function as a new anal sphincter (neosphincter). Non dynamic graciloplasty was not particularly successful because the gracilis is mostly composed of type II, fast-twitch, fatiguable muscle fibres, whereas the sphincter ideally needs to be able to automatically contract for long periods. A neurostimulation device with an impulse generator can be implanted to adapt the muscle to prolonged contraction (dynamic graciloplasty). Over time, the muscle becomes mostly composed of type I, slow twitch, fatigue resistant fibres. The patient uses an external magnetic programming device to deactivate the electrical stimulation, relaxing the muscular contraction and enabling defecation at a voluntary time. [ 3 ] [ 5 ]  Dynamic graciloplasty may be indicated for patients with a completely destroyed anal sphincter or a torn sphincter with a large gap between both ends that is not amenable to repair. The procedure involves detachment of the gracilis from the leg, preserving both its blood supply and innervation. The muscle is then moved to wrap around the anal canal completely, and also attached to the  periosteum  of the inferior ramus of the  pubic bone . Various arrangements are described, depending upon the length of the gracilis. The implanted stimulator electrode is placed intramuscularly (within the muscle), very close to the gracilis nerve, and the impulse generator is placed subcutaneously (under the skin). [ 3 ] [ 5 ]  The success rate of the operation is between 40 and 60%, and varies with surgeon experience. The complication rate is high, (infections 28%, device problems 15%, and
leg pain 13%) but these are usually treatable without influence on the result. A second operation may be required for some complications. When dynamic graciloplasty is successful in curing FI, up to 50% of patients may develop signs and symptoms of  obstructed defecation . [ 3 ] [ 4 ] [ 5 ]


This is also termed artificial anal sphincter or neosphincter. [ 14 ]  The usual surgical approach is through the  perineum  or alternatively via the vagina. The artificial bowel sphincter involves the implantation of 3 components: (i) A fluid filled silicone elastomer cuff placed around the anus, (ii) a liquid filled, pressure-regulating balloon positioned in the peritoneal fat, and (iii) a manual pump connecting these components (placed in either the  labia majora  or the  scrotum ). When the cuff is inflated, the anal canal sealed. The fluid is transferred to the balloon by the manual pump, resulting in deflation of the cuff, opening of the anal canal and allowing for defecation. [ 3 ] [ 4 ] [ 5 ]  This procedure improves FI scores and quality of life, and continence is excellent when the procedure works (successful outcome in 85% patients with a functioning device). The procedure is less technically demanding than the graciloplasty, but there is the disadvantage of using foreign material, which can erode through the anal canal. As with graciloplasty, obstructed defecation may develop with a working device, and may be treated with enemas. Complications include infection, which may warrant temporary removal of the device. [ 3 ] [ 4 ] [ 5 ]  Graciloplasty and artificial anal sphincter both significantly improve continence, with artificial anal sphincter being superior, [ 15 ]  however both methods have high rates of complications. [ 15 ] [ 16 ]


This was originally described as a surgical management for  rectal prolapse . This operation essentially involves encircling the anal canal with implanted foreign material. Various materials have been used, including nylon, silk, fascia strips, silver wire, and
silastic bands. Anal encirclement effectively supplements the anal sphincter, narrowing the anal canal and its barrier function to stool, without altering voluntary control. Since complications are common, and can be serious (fecal impaction, infection, erosion of encirclement through anal canal), modern surgeons prefer to perform colostomy. [ 5 ]


This refers to temperature-controlled radiofrequency energy being delivered to the anal canal, and is marketed as the SECCA procedure. This procedure aims to create a controlled scarring and  stricturing  of the anal canal. [ 1 ]  In theory, it is thought that radiofrequency induced IAS injury may cause collagen deposition and fibrosis (scarring), resulting in the affected area tightening. [ 17 ]  Specialized surgical instrument called a radiofrequency handpiece is used. It has 4 needles which enter the IAS and heat up to 85 °C. This causes the water molecules in the tissue to vibrate with subsequent frictional heating. The hand piece is cooled by water and monitors the temperature of the tissues it is applied to for safety. It is thought that the improvement in FI occurs over time as  collagen  is deposited and the tissues undergo remodeling. [ 18 ]  The procedure is carried out under  local anesthesia  (with or without  conscious sedation ) on an  outpatient  basis. [ 19 ]  There appear to be relatively few serious complications. [ 18 ]
Initial studies of the SECCA procedure have shown promising improvements in quality of life and FI severity scores, however large  randomized control trials  and  systematic reviews  are currently lacking. [ 19 ] [ 20 ]


This procedure involves the surgical creation of a stoma (either an appendicostomy, cecostomy, or sigmoidostomy), which thereafter functions as an irrigation port. This antegrade colonic irrigation aims to introduce fluid to wash out the colon at regular intervals. The idea is to ensure regular emptying of the colon and rectum and hopefully, prevent involuntary loss of bowel content. [ 3 ]  The  Malone antegrade continence enema  (MACE) is where an appendicostomy is created, i.e. the  vermiform appendix  is stitched to the abdominal wall to form a stoma. ACE is often necessary in addition to others when FI is complicated by  neuropathy  and/or an incomplete IAS. Patients may have persistent leakage of fluid per rectum for several hours following the irrigation. [ 1 ]


Diversion may be a temporary measure in the management of FI, e.g. to allow healing of another surgical procedure, or it may be a definitive procedure.  Stoma creation is considered to be the last resort treatment, [ 4 ]  when all other attempts to improve symptoms have been unsuccessful, although they are associated with many problems such as odor associated with leakage of stool and flatus from the stoma.  The  stoma  may be  colostomy  (where the colon is ended in a stoma) or  ileostomy  (where the  ileum  is ended in a stoma).  Both may involve the creation of an  internal waste-holding reservoir  in a procedure developed by Dr.  Nils Kock  in the late 1960s. [ 21 ]


Diversion colitis  is inflammation of the section of gut through which stool no longer passes. This condition arises because normally the lining of the gut obtains some of its nutrients from the fecal stream.  This condition may cause a foul-smelling, mucous  rectal discharge  from the distal, unused colon. [ 5 ]


Transanal irrigation  is medical procedure in which water is used to evacuate feces from the  rectum  and  descending colon  via the  anus . [ 5 ] [ 1 ]


Transanal irrigation uses a large volume water  enema  system. [ 2 ]  It is carried out every day (or every 2 days) by the patient or carer as a long term management for bowel dysfunction, including  fecal incontinence  and/or  constipation  (especially  obstructed defecation ).


Although the procedure and general goals may be similar, transanal irrigation is different from  colon cleansing  (colon hydrotherapy), which is a term used in alternative medicine. Transanal irrigation is used for medical conditions which affect defecation, such as  spinal cord injury  or  multiple sclerosis . Colon cleansing is used outside of mainstream medical supervision, and may be used in the belief that the procedure removes toxins from the body.


The impact of transanal irrigation varies considerably. Some individuals experience complete control of incontinence, and other report little or no benefit. [ 5 ]  Evidence shows this treatment can be considered for children as well. [ 6 ] [ 7 ]  When diet and medication has proven ineffective, transanal irrigation may be used. [ 5 ] [ 8 ]


Transanal irrigation systems may use either a rectal balloon catheter or a cone-shaped colostomy tip. [ 9 ]


The catheter tip is inserted into the anal canal. Systems with balloon catheters require inflation of the balloon once the tip is in position. [ 9 ]  Cone shaped colostomy tip systems must be supported manually. [ 9 ]


Lukewarm tapwater (36-38°C) [ 4 ]  is used if it is drinkable. [ 9 ]   If tap water is not safe for drinking, a different source of clean water is needed. The irrigation bag is ideally placed or hung 1-1.5 m above the level of the toilet. The flow is switched on with a handheld valve. The flow rate of the water may be controlled by a manual pump or a battery pump. [ 9 ]


The volume of water used is normally about 1000 ml. [ 9 ]  Some sources recommend repeat irrigation with a higher volume up to 2300 ml. [ 9 ]


Transanal irrigation may be performed every day or every other day in order to simulate a normal defecation routine. [ 9 ]  Ideally, irrigation is performed at the same hour each day. [ 10 ]


The optimal volume and frequency may be determined by trail and error for each individual patient during the first few months of treatment. [ 9 ]


The time required for the procedure is in the range of 30–120 min. [ 9 ]


Some individuals take oral constipating medications or oral laxative medications in addition to transanal irrigation. [ 9 ]


It is unclear whether the mechanism of action of irrigation is by simple mechanical washing out of the bowel, or by triggering of colonic mass movements, or both. [ 9 ]


Disadvantages of the treatment may include:


Specific conditions for which transanal irrigatio has been used include:


A Cochrane review found evidence that transanal irrigation was more effective compared to conservative management in the management of spinal cord injury. There were more positive benefits for constipation scores, neurogenic bowel dysfunction scores, and fecal incontinence scores. Patients spent less time in total on bowel care and were more satisfied with the treatment. [ 12 ]


The treatment is generally considered safe. However, adverse effects are reported, including:


Bowel perforation  is when the wall of the bowel ruptures. It is a potentially lethal complication [ 9 ]  which requires emergency surgery. 49 bowel perforations caused by transanal irrigation were reported between 2005 and 2013. [ 19 ]  This rate was used to calculate a risk of 2-6 perforations per 1 million procedures. [ 19 ]  This risk of perforation is significantly lower compared to other common medical procedures such as flexible sigmoidoscopy (1 perforation per 40000 procedures), colonoscopy (1 per 1000) and barium enema (1 per 10000). [ 10 ]  However, patients may need to conduct transanal irrigation daily or near-daily for many years, which increases their lifetime risk. [ 9 ]  Perforation is more likely in the first weeks after starting treatment. [ 19 ]  People who have had a surgical anastomosis (for example, after low anterior resection,  stapled transanal rectal resection ,  ventral mesh rectopexy , or other types of surgery for  rectal prolapse ) are more at risk of bowel perforation during transanal irrigation. [ 10 ]


One study reported before and after changes in anorectal physiology tests in patients with idiopathic faecal incontinence or chronic idiopathic constipation. The patients had all used transanal irrigation for at least 30 months. In the chronic idiopathic constipation group there was no reduction in anal sphincter function after long term use of transanal irrigation. In the idiopathic faecal incontinence group anal resting and squeeze pressures were lower after long term use of transanal irrigation. The researchers suggested that this was due to age related changes in sphincter function and the deterioration of the disease over time rather than due to the use of transanal irrigation. In both groups rectal urge volume increased after long term use of transanal irrigation. The researchers suggested that patients get accustomed to larger rectal volumes, and without the irrigation their everyday sensation of urge from the presence of stool in the rectum is decreased. This may encourage patients to continue using the irrigation. However, rectal compliance (how well the rectum can stretch and accommodate increasing volumes without triggering discomfort or pain) and biomechanical properties of the rectal wall were unchanged. [ 3 ]


Ventral rectopexy  is a surgical procedure for external  rectal prolapse , internal rectal prolapse (rectal intussusception), and sometimes other conditions such as  rectocele ,  obstructed defecation syndrome , or  solitary rectal ulcer syndrome . The  rectum  is fixed into the desired position, usually using a biological or synthetic  mesh  which is attached to the  sacral promontory . The effect of the procedure is correction of the abnormal descended position of the posterior compartment of the pelvis (i.e., the rectum), reinforcement of the anterior (front) surface of the rectum, and elevation of the  pelvic floor . [ 3 ]  In females, the rectal-vaginal septum is reinforced, and there is the opportunity to simultaneously correct any prolapse of the middle compartment (i.e., the  uterus ). [ 4 ]  In such cases, ventral rectopexy may be combined with  sacrocolpopexy . [ 5 ] [ 3 ]  The surgery is usually performed  laparoscopically  (via small openings made in the abdomen).


There are over 300 different variations of surgical procedures described for rectal prolapse, and this area has seen rapid development. [ 3 ]  However, there is no clear consensus regarding the best method. [ 6 ]  Surgical treatment for rectal prolapse may be via the perineal or abdominal (transabdominal / peritoneal) approach. [ 5 ] [ 6 ]  Generally speaking, perineal procedures have less complications but higher rates of recurrence compared to abdominal procedures. [ 7 ]  Ventral rectopexy falls into the abdominal procedure category, and can be considered as a type of abdominal rectopexy.


Abdominal rectopexy encompasses several procedures which involve mobilization and fixation of the rectum, with or without resection, via abdominal approach. Some of types of abdominal rectopexy are now rarely or never performed. For example, the Ripstein rectopexy (anterior fixation of mesh below the sacral promontory) and the Wells procedure (involving detachment of the lateral ligaments of the rectum) have been abandoned. [ 8 ]  In general, abdominal rectopexy procedures have been associated with post-operative problems with defecation such as new or worsened constipation, obstructed defecation or fecal incontinence. [ 9 ] [ 2 ]  This does not seem to be a significant problem with ventral rectopexy, [ 2 ]  which represents the most recent development of abdominal rectopexy. In men, mobilization of the rectum may risk the development of  erectile dysfunction . [ 9 ]


Another way of categorizing surgery for prolapse of pelvic organs is suspensive or resective (involving removal of sections of the bowel wall). Ventral rectopexy alone is a syspensive type surgery, a category which also includes  colposacropexy . [ 10 ]  Resection rectopexy additionally involves removal of a section of the  sigmoid colon  ( sigmoidectomy ). It is thought to have decreased post operative problems of constipation, because the redundant colon is removed and therefore cannot "kink". However, there is no evidence that this improves the outcomes, and the necessary creation of an  anastomosis  (surgically created joining between two ends of bowel when a section of bowel is removed) increases the risk of severe complications. [ 8 ]


Ventral rectopexy with an  autologous graft  ( fascia lata ), [ 9 ]  and then with a synthetic mesh for external rectal prolapse was first reported in 1971. [ 11 ]  The Orr-Loygue procedure (lateral mesh rectopexy) was described in 1984. [ 12 ] [ 5 ]  The Orr-Loygue procedure involved anterior and posterior mobilization of the rectum to the level of the levator ani muscle and removal of the pouch of Douglas. Mesh was sutured to the lateral surfaces (sides) of the rectum. [ 1 ]


The Orr-Loygue procedure was modified by D'Hoore in 2004. [ 13 ]  In ventral rectopexy, there is no posterior dissection and mobilization of the rectum apart from to expose the sacral promontory. With no posterior (dorsal) or lateral dissection, damage to the autonomic nerves is minimized. As a result, there are less problems with post-operative constipation. There is no excision of the pouch of Douglas, and the mesh is placed directly onto the anterior (ventral) surface of the rectum. This procedure aims to suspend the middle and lower sections of the rectum. This modified procedure is now known as the anterior rectopexy or ventral rectopexy. [ 1 ]  D'Hoore also used a  laparoscopic  approach (laparoscopic ventral mesh rectopexy, LVMR). [ 14 ]


After 2002, the minimally invasive trans-anal approach known as  Stapled Trans-Anal Rectal Resection  (STARR) became popular for treating  obstructed defecation syndrome . However, over time, there has been a general trend away from STARR towards abdominal rectopexy for surgical treatment of obstructed defecation syndrome. [ 15 ]


Ventral mesh rectopexy has become the one of the most popular options for rectal prolapse. [ 16 ] [ 7 ]  Ventral rectopexy also provides the opportunity to simultaneously correct any prolapse of the middle compartment of the pelvis, [ 4 ]  and is sometimes combined with  sacrocolpopexy . [ 5 ]


There has been some controversy connected with transvaginal placement of mesh in the treatment of  pelvic organ prolapse  and  stress urinary incontinence . This is because there is a risk of erosion (tissue breakdown around the mesh) and sepsis (infection). [ 4 ]  In 2008 and 2016 the  US Food and Drug Administration  published guidance about potential serious complications caused by such meshes and upgraded their risk classification of such meshes from Class II (moderate risk) to Class III (high risk). Procedures involving transvaginal mesh have since decreased by 40–60% in the USA. [ 14 ]  In 2011, manufacturers of permanent transvaginal meshes withdrew the products from the market. [ 17 ]  In Europe, the  Scientific Committee on Emerging and Newly Identified Health Risks  (SCENIHR) stated in 2015 that implantation of any mesh via the vaginal route should be done only in complicated cases where a primary repair has failed. [ 14 ]  A  Cochrane review  in 2016 stated that the risks were higher with such meshes compared to native tissue repair (using the patient's own tissues instead of mesh). [ 17 ]  Transvaginal meshes have higher risk of repeat surgery, injury to the bladder, and stress urinary incontinence which appears after the surgery. [ 17 ]  They concluded that transvaginal meshes have limited benefit in the primary surgical management of pelvic organ prolapse and stress urinary incontinence. [ 17 ] [ needs update ]  The review was updated in 2024 with the same conclusions but based on newly available evidence. [ 18 ]


In response to the controversy connected with transvaginal meshes, the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland issued a position statement regarding the use of mesh in ventral rectopexy in 2020. They stated that meshes in ventral rectopexy are not the same because the mesh is inserted between the rectum and the vagina and not directly into the vagina as with transvaginal meshes. [ 14 ]  They also stated that according to current evidence ventral mesh rectopexy is the best available treatment to restore normal rectal function, and that the estimated overall risk of complications is about 2.5% based on the worst-case scenario. [ 14 ]


The definitive indication for ventral rectopexy is:


Relative indications are:


Absolute contraindications are:


Relative contraindications are:


There are 3 options for surgical approach: open abdominal surgery, laparoscopic approach or  robotic surgery . The laparoscopic approach is safer than open surgery, [ 4 ]  and there is less risk of complications after the procedure. [ 23 ]  There is also less blood loss, less pain after the procedure, shorter average length of stay in hospital and faster recovery. [ 8 ] [ 23 ]  Rarely, the procedure must be converted into an open abdominal surgery. [ 7 ]


The procedure is still almost always carried out via laparoscopic approach. [ 14 ]  However, increasingly some surgeons use robotic surgery to conduct the procedure. [ 5 ]  Some surgeons claim that the use of robotic surgery makes ventral rectopexy less technically demanding, because it requires careful dissection and suture placement in a tight, narrow space. [ 1 ]  This is especially true in patients with a narrow pelvis. [ 16 ]  Laparoscopic ventral rectopexy is also difficult in patients who are obese. [ 8 ]


Robotic approach has the benefit of three-dimensional visualization, precise dissection and the possibility of refined, articulated movements suitable for a narrow conical space such as the pelvis. [ 16 ]  There is less trauma to the tissues and less blood loss compared to conventional laparoscopy. [ 8 ]  In the case of ventral rectopexy, which is considered a difficult procedure requiring a lot of training (100 cases), robotic surgery is reported to speed up the learning curve for surgeons (20 cases). [ 8 ]  Longer operation times are usually reported with robotic surgery, but operation time is less With surgeons who are experienced in using the robotic technique. [ 8 ]  The laparoscopic approach is cheaper than robotic surgery, [ 16 ]  but when considering the reduced hospital stay, robotic surgery may be cheaper overall. [ 8 ]


The choice of synthetic material used to perform the rectopexy may also vary and can include nylon, Teflon, Marlex, Ivalon, Gore‐Tex, Vicryl or Dexon. There is debate regarding the best mesh material, and whether a biologic or synthetic mesh is superior. One systematic review found no significant difference between biologic or synthetic mesh with regards to the rates of mesh erosion or recurrence of prolapse. [ 21 ]  However, a later systematic review reported lower rate of mesh erosion for biologic mesh (0.22%) compared to synthetic mesh (1.87%). [ 23 ]


Usually one strip of mesh is placed, but sometimes two are used. [ 7 ]  The meshes are 15, 17 or 20 cm long. [ 7 ]  Tackers (Protack), titanium screw tacks, or sutures (absorbably or non-absorbable) are used to fix the mesh to the sacral promontory. [ 7 ]  Absorbable or non-absorbable sutures (Ethibond, prolypropylene), or 4mm titanium staples are used to fix the mesh to anterior rectal wall. [ 7 ]


After the procedure, patients are advised to avoid sex and lifting heavy weights, and to use laxatives for 6 weeks. [ 5 ]  Continuing pelvic floor physical therapy may be beneficial in those cases where people had symptoms of obstructed defecation or incontinence before the procedure. [ 5 ]


According to one publication, risk of a complication occurring is 14%. [ 5 ]  Another systematic review reported an average complication rate of 4.8%. [ 7 ]  Complications involving the urinary tract are most common and mesh related complications are less common. [ 5 ]


Recurrence of the prolapse after ventral rectopexy is possible. Recurrence rates are reported as between 1.4 and 9.7% of cases. Recurrence occurs sooner and the overall rate is higher when ventral rectopexy is performed on a prolapse which has already recurred in the past (25% of cases after 5 years). Risk factors for recurrence after ventral rectopexy include old age, male gender, higher  body mass index , higher Cleveland Clinic incontinence score, prolonged  pudendal nerve terminal motor latency , weak pelvic floor, [ 5 ] [ 7 ]   benign joint hypermobility syndrome , [ 4 ]  and excessive perineal descent associated with chronic straining. [ 4 ]  Mesh of 20 cm length has lower risk of recurrence than mesh of 15–17 cm. [ 5 ]  Recurrence may occur as either full thickness prolapse or mucosal prolapse. [ 7 ]


Recurrence may occur if the mesh slips from the sacral promontory. This may happen because of inadequate fixation and adherence of the mesh to the anterior rectal wall or to the sacral promontory, or incorrectly placed staples to the upper sacrum. [ 5 ] [ 7 ]  Another technical reason for relapse is inadequate dissection on the anterior aspect of the rectum. [ 7 ]  Recurrence can be a challenging situation for surgeons, [ 7 ]  and in this case the patient is re-evaluated for 6 months to identify the reason for the recurrence. [ 5 ]  A further surgical procedure to re-fix the mesh may be required. [ 5 ]


Overall risk of complications associated with the mesh have been reported as 2.5%. [ 14 ]  Such complications include detachment and migration of the mesh. This complication is reported at a rate of 4.6% of cases. [ 5 ]  The mesh can erode into the vagina (1.3% of cases), or into the rectum.  The risk of mesh complications appears to be low regardless of what mesh material is used. [ 21 ]  However, biologic mesh may have a lower risk of complications compared to synthetic mesh. [ 23 ]  When suturing synthetic mesh to the rectum, the use of absorbable sutures leads to lower risk of complications compared to non-resorbable sutures. [ 5 ]   When mesh erosion into the vagina occurs, a further surgical procedure is required to remove the tissue from the mesh and to close the vaginal wall over the defect. [ 5 ]  Most mesh-related complications can be treated successfully. [ 5 ]


At the site where the mesh is attached (lumbosacral region), vertebral  discitis  may occur. This is a rare but serious complication. In one case, the discitis may have been caused by the use of titanium screws. Signs and symptoms of discitis include chronic back pain and infection. Discitis is treated with intravenous antibiotics and possible removal of the mesh. [ 5 ]


Urinary-related complications include  urinary tract infection ,  urinary retention , damage to structures like the  ureter ,  bladder  or  vas deferens . [ 5 ]


Other possible complications are infection or hernia at the port site,  ileus  and small bowel injury. [ 7 ]


The average improvement in fecal incontinence is reported as 62.5 [ 7 ]  to 79.3%, [ 5 ]  and the average improvement in constipation from 76.6% [ 7 ]  to 71%. [ 5 ]  However, these conditions may not fully resolve after the procedure. [ 5 ]  Ventral rectopexy may be more effective as an initial surgical repair of a prolapse rather than treatment for a recurrent prolapse which was previously operated upon. [ 5 ]


One systematic review comparing laparoscopic ventral mesh rectopexy and robotic ventral mesh rectopexy concluded that robotic approach resulted in a longer operation time. [ 16 ]  However, this may be related to lack of operator experience with the robotic platform, and it has been suggested that a surgeon who is experienced with the robotic approach can perform the operation as fast or faster than a surgeon who is experienced with the laparoscopic approach. The robotic approach resulted in a shorter stay in hospital for patients, which balanced the increased cost of the robotic surgery itself. This may be because robotic surgery is more precise and leads to less bleeding and pain after the procedure. One study showed lower scores for obstructed defecation after robotic approach. In general, both approaches showed improvement in function and quality of life, but some studies reported robotic approach as giving slightly more improvement in quality of life. Both approaches resulted in similar long term outcome and recurrence rates. The review authors concluded that robotic ventral mesh rectopexy is safe and results in at least the same outcomes as laparoscopic approach. [ 16 ]


The most commonly used material for synthetic mesh is polypropylene. This material has a lower risk of mesh exposure compared to polyester. [ 19 ]  The two most common biologic mesh products are Permacol, which is cross-linked collagen, and Biodesign, which is non-cross linked. It is not known if one type of biologic mesh is better. [ 19 ]


In 2020 another systematic review compared the use of synthetic mesh and biologic mesh in ventral mesh rectopexy for external rectal prolapse or symptomatic internal rectal prolapse. [ 19 ]  The review included 32 studies containing a total of 4001 cases where synthetic mesh was used and 762 where biologic mesh was used. The rate of mesh-related complications ranged from 0 to 2.4% for synthetic mesh, with a pooled incidence rate of 1%. The rate of mesh-related complications ranged from 0 and 0.7% for biologic mesh. The rate of recurrence ranged from 1.1 to 18.8% for synthetic mesh. The rate of recurrence ranged from 0 to 15.4% for biologic mesh. The reviewers stated that the risk of mesh related complications are low for both synthetic and biologic mesh, and there may a small reduction in mesh-related complications with biologic mesh. However, due to lack of sufficient high quality data for biologic mesh, they were unable to make definitive conclusions. [ 19 ]


One systematic review compared laparoscopic suture rectopexy with laparoscopic mesh rectopexy in the treatment of full-thickness rectal prolapse (external rectal prolapse, complete rectal prolapse). Compared to suture rectopexy, mesh rectopexy had lower rate of recurrence and longer operation time. There were no differences in degree of improvement of constipation, incontinence, bleeding during the surgery, length of stay in hospital, and overall rate of complications after the surgery. [ 24 ]


The  American Board of Thoracic Surgery  is an  American  surgical  organization  devoted to  thoracic surgery. [ 1 ]  The ABTS will soon shut down their access to the Self-Education Self Assessment in Thoracic Surgery.


This article about a medical organization or association is a  stub . You can help Wikipedia by  expanding it .


The  Association of Cardiothoracic Surgical Assistants (ACSA)  is a professional body in the  United Kingdom  that ACSA represents a body of non-medical practitioners working in  cardiothoracic surgery , performing a range of skilled interventions. It was formed in 1997. [ 1 ]


The ACSA supports its members by providing educational meetings, discussion forums and professional advice. Members also can receive indemnity cover at a reduced cost from the  Medical Protection Society  and receive a newsletter, have access to a members' forum and to archived educational material. ACSA represents its members in the  Society of Cardiothoracic Surgery  and has helped to develop the  National Curriculum  framework for surgical care practitioners.


In 1997, 12 surgical assistants from the UK met to discuss the future of cardiothoracic surgical assistants in the UK; a motion was passed to form the Association of Cardiothoracic Surgical Assistants (ACSA). Richard Ward was elected as its inaugural president, and the association identified the need for a support network and standard education and qualification practices.


The same year, the Society of Cardiothoracic Surgery, the Royal College of Surgeons of Great Britain and Ireland and ACSA formulated the Surgeons' Assistant Diploma in Cardiothoracic Surgery. In 1998, ACSA identified a need to run a revision course for future candidates for the diploma. This course has since run with great success.


In 2004, the title of Surgical Practitioner was reviewed by the United Kingdom Department of Health. The title was later changed once again to "Surgical Care Practitioner (SCP)". This title is still used today although it should be said that it is still only a working title due to disputes with other groups. The same year, work began on the National Curriculum Framework for SCPs, started by the Department of Health.


ACSA worked with many other organisations including the Royal College of Surgeons, the  National Association of Assistants in Surgical Practice , the  Association for Perioperative Practice , the  Association of Surgeons in Training , the  Association of Operating Department Practitioners , the  British Orthopaedic Trainees Association , and the  Royal College of Obstetricians and Gynaecologists .


In 2006 the National Curriculum framework was published. In 2007 ACSA and SCTS decided to start holding their  Annual General Meetings  to coincide with each other.


Steven Bryant went on to become president of ACSA for two years, during this time Steven attended many meetings at the RCS and other organisations such as the 'new ways of working' department, set up  by the last government to discuss the future development of the surgical assistant/care practitioner. He is widely credited as one of the leading lights in the profession and in 2011 became the first non-medically qualified practitioner to become an examiner for the RCS diploma. Steven Bryant continues to work at Papworth hospital in Cambridgeshire as the lead scp Papworth Hospital is regarded as one of the main training centres for SA/SCP  training in the UK and abroad.


Cardiothoracic surgery  is the  field  of  medicine  involved in  surgical treatment  of organs inside the  thoracic cavity  — generally treatment of conditions of the  heart  ( heart disease ),  lungs  ( lung disease ), and other  pleural  or  mediastinal  structures.


In most countries, cardiothoracic surgery is further  subspecialized  into  cardiac surgery  (involving the heart and the  great vessels ) and  thoracic surgery  (involving the lungs,  esophagus ,  thymus , etc.); the exceptions are the  United States ,  Australia ,  New Zealand , the  United Kingdom ,  India  and some  European Union  countries such as  Portugal . [ 1 ]


A cardiac surgery  residency  typically comprises anywhere from four to six years (or longer) of training to become a fully qualified surgeon. [ 2 ]  Cardiac surgery training may be combined with thoracic surgery and/or  vascular surgery  and called cardiovascular (CV) / cardiothoracic (CT) / cardiovascular thoracic (CVT) surgery. Cardiac surgeons may enter a cardiac surgery residency directly from  medical school , or first complete a  general surgery  residency followed by a  fellowship . Cardiac surgeons may further sub-specialize cardiac surgery by doing a fellowship in a variety of topics including  pediatric  cardiac surgery,  cardiac transplantation , adult-acquired heart disease, weak heart issues, and many more problems in the heart. [ citation needed ]


The highly competitive Surgical Education and Training (SET) program in Cardiothoracic Surgery is six years in duration, usually commencing several years after completing medical school. Training is administered and supervised via a bi-national (Australia and New Zealand) training program. Multiple examinations take place throughout the course of training, culminating in a final fellowship exam in the final year of training.  Upon completion of training, surgeons are awarded a Fellowship of the  Royal Australasian College of Surgeons  (FRACS), denoting that they are qualified specialists.  Trainees having completed a training program in General Surgery and have obtained their FRACS will have the option to complete fellowship training in Cardiothoracic Surgery of four years in duration, subject to college approval. It takes around eight to ten years minimum of post-graduate (post-medical school) training to qualify as a cardiothoracic surgeon. Competition for training places and for public (teaching) hospital places is very high currently, leading to concerns regarding  workforce planning  in Australia. [ citation needed ]


Historically, cardiac surgeons in  Canada  completed general surgery followed by a fellowship in CV / CT / CVT.  During the 1990s, the Canadian cardiac surgery training programs changed to six-year "direct-entry" programs following medical school. The direct-entry format provides residents with experience related to cardiac surgery they would not receive in a general surgery program (e.g.  echocardiography ,  coronary care unit , cardiac catheterization etc.). Residents in this program will also spend time training in thoracic and  vascular surgery . Typically, this is followed by a fellowship in either Adult Cardiac Surgery, Heart Failure/Transplant, Minimally Invasive Cardiac Surgery, Aortic Surgery, Thoracic Surgery, Pediatric Cardiac Surgery or Cardiac ICU. Contemporary Canadian candidates completing general surgery and wishing to pursue cardiac surgery often complete a cardiothoracic surgery fellowship in the United States. The Royal College of Physicians and Surgeons of Canada also provides a three-year cardiac surgery fellowship for qualified general surgeons that is offered at several training sites including the  University of Alberta , the  University of British Columbia  and the  University of Toronto . [ citation needed ]


Thoracic surgery is its own separate 2–3 year fellowship of general or cardiac surgery in Canada.


Cardiac surgery programs in Canada: [ citation needed ]


Cardiac surgery training in the  United States  is combined with general  thoracic surgery  and called cardiothoracic surgery or thoracic surgery.  A cardiothoracic surgeon in the U.S. is a physician who first completes a  general surgery  residency (typically 5–7 years), followed by a cardiothoracic surgery fellowship (typically 2–3 years). The cardiothoracic surgery fellowship typically spans two or three years, but certification is based on the number of surgeries performed as the operating surgeon, not the time spent in the program, in addition to passing rigorous board certification tests.  Two other pathways to shorten the duration of training have been developed: (1) a combined general-thoracic surgery residency consisting of four years of general surgery training and three years of cardiothoracic training at the same institution and (2) an integrated six-year cardiothoracic residency (in place of the general surgery residency plus cardiothoracic residency), which have each been established at many programs (over 20). [ 3 ]   Applicants match into the integrated six-year (I-6) programs directly out of medical school, and the application process has been extremely competitive for these positions as there were approximately 160 applicants for 10 spots in the U.S. in 2010.  As of May 2013, there are 20 approved programs, which include the following:


Integrated six-year Cardiothoracic Surgery programs in the United States: [ citation needed ]


The  American Board of Thoracic Surgery  offers a special pathway certificate in congenital cardiac surgery which typically requires an additional year of fellowship. This formal certificate is unique because congenital cardiac surgeons in other countries do not have formal evaluation and recognition of pediatric training by a licensing body.


The earliest operations on the  pericardium  (the sac that surrounds the heart) took place in the 19th century and were performed by  Francisco Romero  (1801) [ 4 ]   Dominique Jean Larrey ,  Henry Dalton , and  Daniel Hale Williams . [ 5 ]  The first surgery on the heart itself was performed by  Norwegian  surgeon  Axel Cappelen  on 4 September 1895 at  Rikshospitalet  in Kristiania, now  Oslo . He  ligated  a bleeding  coronary artery  in a 24-year-old man who had been stabbed in the left  axilla  and was in deep  shock  upon arrival. Access was through a left  thoracotomy . The patient awoke and seemed fine for 24 hours, but became ill with increasing temperature and he ultimately died from what the  post mortem  proved to be  mediastinitis  on the third postoperative day. [ 6 ] [ 7 ]  The first successful surgery of the heart, performed without any complications, was by  Ludwig Rehn  of  Frankfurt ,  Germany , who repaired a stab wound to the right  ventricle  on September 7, 1896. [ 8 ] [ 9 ]


Surgery in  great vessels  ( aortic coarctation  repair,  Blalock-Taussig shunt  creation, closure of  patent ductus arteriosus ) became common after the turn of the century and falls in the domain of cardiac surgery, but technically cannot be considered heart surgery.  One of the more commonly known cardiac surgery procedures is the  coronary artery bypass graft (CABG) , also known as "bypass surgery."


In 1925 operations on the  heart valves  were unknown.  Henry Souttar  operated successfully on a young woman with  mitral stenosis . He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years [ 10 ]  but Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue. [ 11 ] [ 12 ]


Cardiac surgery changed significantly after  World War II . In 1948 four surgeons carried out successful operations for  mitral stenosis  resulting from  rheumatic fever .  Horace Smithy  (1914–1948) revived an operation due to Dr  Dwight Harken  of the  Peter Bent Brigham Hospital  using a punch to remove a portion of the  mitral valve .  Charles Bailey  (1910–1993) at the  Hahnemann Hospital ,  Philadelphia ,  Dwight Harken  in  Boston  and  Russell Brock  at  Guy's Hospital  all adopted Souttar's method. All these men started work independently of each other, within a few months. This time Souttar's technique was widely adopted although there were modifications. [ 11 ] [ 12 ]


In 1947  Thomas Holmes Sellors  (1902–1987) of the  Middlesex Hospital  operated on a  Fallot's Tetralogy  patient with  pulmonary stenosis  and successfully divided the stenosed  pulmonary valve . In 1948,  Russell Brock , probably unaware of Sellor's work, used a specially designed dilator in three cases of  pulmonary stenosis . Later in 1948 he designed a punch to resect the  infundibular muscle   stenosis  which is often associated with  Fallot's Tetralogy . Many thousands of these "blind" operations were performed until the introduction of heart bypass made direct surgery on valves possible. [ 11 ]


Open heart surgery is a procedure in which the patient's heart is opened and surgery is performed on the internal structures of the heart. It was discovered by  Wilfred G. Bigelow  of the  University of Toronto  that the repair of intracardiac pathologies was better done with a bloodless and motionless environment, which means that the heart should be stopped and drained of blood. The first successful intracardiac correction of a  congenital heart defect  using  hypothermia  was performed by  C. Walton Lillehei  and  F. John Lewis  at the  University of Minnesota  on September 2, 1952. The following year,  Soviet  surgeon  Aleksandr Aleksandrovich Vishnevskiy  conducted the first cardiac surgery under  local anesthesia . [ citation needed ]


Surgeons realized the limitations of hypothermia – complex intracardiac repairs take more time and the patient needs blood flow to the body, particularly to the  brain . The patient needs the function of the heart and  lungs  provided by an artificial method, hence the term  cardiopulmonary bypass .  John Heysham Gibbon  at Jefferson Medical School in Philadelphia reported in 1953 the first successful use of extracorporeal circulation by means of an  oxygenator , but he abandoned the method, disappointed by subsequent failures. In 1954 Lillehei realized a successful series of operations with the controlled cross-circulation technique in which the patient's mother or father was used as a ' heart-lung machine '.  John W. Kirklin  at the  Mayo Clinic  in Rochester, Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations, and was soon followed by surgeons in various parts of the world. [ citation needed ]


Nazih Zuhdi  performed the first total intentional hemodilution open heart surgery on Terry Gene Nix, age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a success; however, Nix died three years later in 1963. [ 13 ]  In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age  3 + 1 ⁄ 2 , using the total intentional hemodilution machine. In 1985 Zuhdi performed Oklahoma's first successful heart transplant on Nancy Rogers at Baptist Hospital. The transplant was successful, but Rogers, who had  cancer , died from an infection 54 days after surgery. [ 14 ]


Since the 1990s, surgeons have begun to perform " off-pump bypass surgery " – coronary artery bypass surgery without the aforementioned  cardiopulmonary bypass . In these operations, the heart is beating during surgery, but is stabilized to provide an almost still work area in which to connect the conduit vessel that bypasses the blockage; in the U.S., most conduit vessels are harvested endoscopically, using a technique known as  endoscopic vessel harvesting  (EVH). [ citation needed ]


Some researchers believe that the off-pump approach results in fewer post-operative complications, such as  postperfusion syndrome , and better overall results. Study results are controversial as of 2007, the surgeon's preference and hospital results still play a major role. [ citation needed ]


A new form of heart surgery that has grown in popularity is  robot-assisted heart surgery . This is where a machine is used to perform surgery while being controlled by the heart surgeon. The main advantage to this is the size of the incision made in the patient. Instead of an incision being at least big enough for the surgeon to put his hands inside, it does not have to be bigger than 3 small holes for the robot's much smaller "hands" to get through. [ citation needed ]


Pediatric cardiovascular surgery is surgery of the heart of children. The first operations to repair cardio-vascular [ 15 ]  defects in children were performed by Clarence Crafoord in Sweden when he repaired coarctation of the aorta in a 12-year-old boy. [ 16 ]  The first attempts to palliate congenital heart disease were performed by Alfred Blalock with the assistance of William Longmire, Denton Cooley, and Blalock's experienced technician, Vivien Thomas in 1944 at Johns Hopkins Hospital. [ 17 ]   Techniques for repair of congenital heart defects without the use of a bypass machine were developed in the late 1940s and early 1950s.  Among them was an open repair of an atrial septal defect using hypothermia, inflow occlusion and direct vision in a 5-year-old child performed in 1952 by Lewis and Tauffe. C. Walter Lillihei used cross-circulation between a boy and his father to maintain perfusion while performing a direct repair of a ventricular septal defect in a 4-year-old child in 1954. [ 18 ]  He continued to use cross-circulation and performed the first corrections of tetralogy of Fallot and presented those results in 1955 at the American Surgical Association. In the long-run, pediatric cardiovascular surgery would rely on the cardiopulmonary bypass machine developed by Gibbon and Lillehei as noted above. [ citation needed ]


The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the mortality rates of these surgeries to relatively low ranks. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates. [ 19 ] [ 20 ]  A major concern with cardiac surgery is the incidence of  neurological  damage.  Stroke  occurs in 5% of all people undergoing cardiac surgery, and is higher in patients at risk for stroke. [ 21 ]  A more subtle constellation of  neurocognitive deficits  attributed to  cardiopulmonary bypass  is known as  postperfusion syndrome , sometimes called "pumphead". The symptoms of postperfusion syndrome were initially felt to be permanent, [ 22 ]  but were shown to be transient with no permanent neurological impairment. [ 23 ]


To assess the performance of surgical units and individual surgeons, a popular risk model has been created called the  EuroSCORE .  This takes a number of health factors from a patient and using precalculated logistic regression coefficients attempts to give a percentage chance of survival to discharge.  Within the UK this EuroSCORE was used to give a breakdown of all the centres for cardiothoracic surgery and to give some indication of whether the units and their individual surgeons performed within an acceptable range. The results are available on the CQC website. [ 24 ]   The precise methodology used has however not been published to date nor has the raw data on which the results are based. [ citation needed ]


Infection represents the primary non-cardiac complication from cardiothoracic surgery. Infections include mediastinitis, infectious myo- or pericarditis, endocarditis, cardiac device infection, pneumonia, empyema, and bloodstream infections.  Clostridioides difficile  colitis can develop when prophylactic or post-operative antibiotics are used.


Post-operative patients of cardiothoracic surgery are at risk of nausea, vomiting, dysphagia, and aspiration pneumonia. [ 25 ]


A pleurectomy is a surgical procedure in which part of the  pleura  is removed. It is sometimes used in the treatment of  pneumothorax  and  mesothelioma . [ 26 ]  In case of pneumothorax, only the apical and the diaphragmatic portions of the parietal pleura are removed. [ citation needed ]


Lung volume reduction surgery, or LVRS, can improve the quality of life for certain patients with  COPD  of  emphysematous  type, when other treatment options are not enough. Parts of the  lung  that are particularly damaged by emphysema are removed, allowing the remaining, relatively good lung to expand and work more efficiently.  The beneficial effects are correlated with the achieved reduction in residual volume. [ 27 ]   Conventional LVRS involves  resection  of the most severely affected areas of emphysematous, non- bullous  lung (aim is for 20–30%). This is a surgical option involving a  mini-thoracotomy  for patients in end stage COPD due to underlying emphysema, and can improve lung  elastic recoil  as well as  diaphragmatic function . [ citation needed ]


The National Emphysema Treatment Trial (NETT) was a large multicentre study (N = 1218) comparing LVRS with non-surgical treatment. Results suggested that there was no overall survival advantage in the LVRS group, except for mainly upper-lobe emphysema + poor exercise capacity, and significant improvements were seen in exercise capacity in the LVRS group. [ 28 ]  Later studies have shown a wider scope of treatment with better outcomes. [ 29 ]


Possible complications of LVRS include prolonged air leak (mean duration post surgery until all  chest tubes  removed is 10.9 ± 8.0 days. [ 30 ]


In people who have a predominantly upper lobe emphysema, lung volume reduction surgery could result in better health status and lung function, though it also increases the risk of early mortality and adverse events. [ 31 ]


LVRS is used widely in Europe, though its application in the United States is mostly experimental. [ 32 ]


A less invasive treatment is available as a  bronchoscopic lung volume reduction  procedure. [ 33 ]


Not all lung cancers are suitable for surgery. The  stage , location and cell type are important limiting factors. In addition, people who are very ill with a poor  performance status  or who have inadequate pulmonary reserve would be unlikely to survive. Even with careful selection, the overall operative death rate is about 4.4%. [ 34 ]


In  non-small cell lung cancer staging , stages IA, IB, IIA, and IIB are suitable for surgical resection. [ 35 ]


Pulmonary reserve is measured by  spirometry . If there is no evidence of undue shortness of breath or  diffuse parenchymal lung disease , and the FEV 1  exceeds 2 litres or 80% of predicted, the person is fit for  pneumonectomy . If the FEV 1  exceeds 1.5 litres, the patient is fit for lobectomy. [ 36 ]


There is weak evidence to indicate that participation in exercise programs before lung cancer surgery may reduce the risk of complications after surgery. [ 37 ]


A prolonged air leak (PAL) can occur in 8–25% of people following lung cancer surgery. [ 38 ] [ 39 ]  This complication delays chest tube removal and is associated with an increased length of hospital stay following a lung resection (lung cancer surgery). [ 40 ] [ 41 ]  The use of  surgical sealants  may reduce the incidence of prolonged air leaks, however, this intervention alone has not been shown to results in a decreased length of hospital stay following lung cancer surgery. [ 42 ]


There is no strong evidence to support using  non-invasive positive pressure ventilation  following lung cancer surgery to reduce pulmonary complications. [ 43 ]


The  European Association for Cardio-Thoracic Surgery  ( EACTS ) is a membership organisation devoted to the practice of  cardiothoracic surgery . The mission statement of the association is to advance education in the field of cardiac, thoracic and vascular interventions; and promote research into cardiovascular and thoracic physiology, pathology and therapy, with the aim to correlate and disseminate the results for the public benefit. Within the EACTS there is a large number of committees working on various issues in order to improve cardio-thoracic surgery. [ 1 ]


EACTS was founded as a  European  organisation. However, its membership is now spread all over the world in all continents representing some 70 countries. Since its foundation in 1986 more than 3500 members have been admitted, and the interest in applying for membership has grown considerably during the last few years. [ 2 ]


The EACTS Annual Meeting is the largest cardio-thoracic meeting in the world [ citation needed ]  focusing on scientific developments and research in the following specialities: Acquired Cardiac Disease, Congenital Heart Disease, Vascular Disease and Thoracic Disease. [ citation needed ]


The EACTS publishes two journals focused on high-quality research and cardio thoracic surgery education and one website featuring video based cardio-thoracic tutorials these are:  European Journal of Cardio-Thoracic Surgery (EJCTS) ,  Interactive Cardiovascular and Thoracic Surgery (ICVTS) , and  Multimedia Manual of Cardio-Thoracic Surgery (MMCTS)   [ citation needed ]


The Quality Improvement Programme was launched in 2012 to facilitate continuing improvement of clinical outcomes in adult cardiac surgery through improving education, and various research initiatives. [ citation needed ]


The organisation has collaborated with the  European Society of Cardiology , the  American Heart Association ,  Oxford University , and other organizations to produce clinical practice guidelines and consensus statements related to the treatment of cardiovascular disease. [ 3 ] [ 4 ] [ 5 ]


Hyperhidrosis  is a  medical condition  in which a person exhibits excessive  sweating , [ 1 ] [ 2 ]  more than is required for the  regulation of body temperature . [ 3 ]  Although it is primarily a physical burden, hyperhidrosis can deteriorate the quality of life of the people who are affected from a psychological, emotional, and social perspective. [ 4 ]  In fact, hyperhidrosis almost always leads to psychological as well as physical and social consequences. [ 5 ]  People suffering from it present difficulties in professional fields, more than 80% experiencing a moderate to severe emotional impact from the disease [ 6 ]  and half are subject to  depression .


This excess of sweat happens even if the person is not engaging in tasks that require muscular effort, and it does not depend on the exposure to heat. [ 7 ]  Common places to sweat can include underarms, face, neck, back, groin, feet, and hands. It has been called by some researchers 'the silent handicap'. [ 8 ]


Both  diaphoresis  and  hidrosis  can mean either  perspiration  (in which  sense  they are  synonymous  with  sweating [ 9 ] [ 10 ] ) or  excessive perspiration , in which case they refer to a specific, narrowly defined, clinical disorder.


Hyperhidrosis can either be  generalized , or  localized  to specific parts of the body. Hands, feet, armpits, groin, and the facial area are among the most active regions of perspiration due to the high number of  sweat glands  ( eccrine glands  in particular) in these areas. When excessive sweating is localized (e.g. palms, soles, face, underarms, scalp) it is referred to as  primary  hyperhidrosis or  focal hyperhidrosis . Excessive sweating involving the whole body is termed  generalized  hyperhidrosis or secondary hyperhidrosis. It is usually the result of some other, underlying condition. [ citation needed ]


Primary or  focal  hyperhidrosis may be further divided by the area affected, for instance, palmoplantar hyperhidrosis (symptomatic sweating of only the hands or feet) or  gustatory hyperhidrosis  (sweating of the face or chest a few moments after eating certain foods). [ 1 ]


Hyperhidrosis can also be classified by onset, either congenital (present at birth) or acquired (beginning later in life). Primary or  focal hyperhidrosis  usually starts during adolescence or even earlier and seems to be inherited as an  autosomal  dominant genetic trait. It must be distinguished from  secondary  hyperhidrosis, which can start at any point in life, but usually presents itself after 25 years of age. Secondary hyperhidrosis commonly accompanies conditions such as diabetes mellitus, Parkinson's disease, hyperthyroidism, hyperpituitarism, anxiety disorder, pheochromocytoma, and menopause. [ 11 ]


One classification scheme uses the amount of skin affected. [ 12 ]  In this scheme, excessive sweating in an area of 100  cm 2  (16  in 2 ) or more is differentiated from sweating that affects only a small area. [ 13 ]


Another classification scheme is based on possible causes of hyperhidrosis. [ citation needed ]


The cause of primary hyperhidrosis is unknown.  Anxiety  or excitement can exacerbate the condition. A common complaint of people is a nervous condition associated with sweating, then  sweat more because the person is nervous . Other factors can play a role, including certain  foods  and  drinks ,  nicotine ,  caffeine , and  smells . [ citation needed ]


Similarly, secondary (generalized) hyperhidrosis has many causes including certain types of  cancer , disturbances of the  endocrine system ,  infections , and medications. [ citation needed ]


Primary (focal) hyperhidrosis has many causes.


A variety of cancers have been associated with the development of secondary hyperhidrosis including  lymphoma ,  pheochromocytoma ,  carcinoid  tumors (resulting in  carcinoid syndrome ), and tumors within the  thoracic cavity . [ 4 ]


Certain endocrine conditions are also known to cause secondary hyperhidrosis including  diabetes mellitus  (especially when  blood sugars are low ),  acromegaly ,  hyperpituitarism ,  pheochromocytoma  (tumor of the  adrenal glands , present in 71% of patients) and various forms of  thyroid disease . [ 4 ]


Use of  selective serotonin reuptake inhibitors  (e.g.,  sertraline ) is a common cause of medication-induced secondary hyperhidrosis. [ 4 ]  Other medications associated with secondary hyperhidrosis include  tricyclic antidepressants ,  stimulants ,  opioids ,  nonsteroidal anti-inflammatory drugs  (NSAIDs),  glyburide ,  insulin ,  anxiolytic  agents,  adrenergic agonists , and  cholinergic agonists . [ 4 ]


Symmetry of excessive sweating in hyperhidrosis is most consistent with primary hyperhidrosis. [ 4 ]  To diagnose this condition, a dermatologist gives the person a physical exam. This includes looking closely at the areas of the body that sweat excessively. A dermatologist also asks very specific questions. This helps the physician understand why the person has excessive sweating. Sometimes medical testing is necessary. Some patients require a test called the sweat test. This involves coating some of their skin with a powder that turns purple when the skin gets wet. [ citation needed ]


Excessive sweating affecting only one side of the body is more suggestive of secondary hyperhidrosis and further investigation for a neurologic cause is recommended. [ 4 ]


Antihydral cream is one of the solutions prescribed for hyperhidrosis for palms. [ 14 ] [ 15 ]  Topical agents for hyperhidrosis therapy include  formaldehyde  lotion and topical anticholinergics. These agents reduce perspiration by  denaturing   keratin , in turn occluding the pores of the  sweat glands . They have a short-lasting effect. Formaldehyde is classified as a probable human  carcinogen . Contact sensitization is increased, especially with formalin.  Aluminium chlorohydrate  is used in regular  antiperspirants . However, hyperhidrosis requires solutions or gels with a much higher concentration. These antiperspirant solutions or hyperhidrosis gels are especially effective for treatment of  axillary  or underarm regions. It takes three to five days to see improvement. The most common side-effect is  skin irritation . For severe cases of plantar and palmar hyperhidrosis, there has been some success with conservative measures such as higher strength aluminium chloride antiperspirants. [ 16 ]  Treatment algorithms for hyperhidrosis recommend topical antiperspirants as the first line of therapy for hyperhidrosis. The International Hyperhidrosis Society has published evidence-based treatment guidelines for  focal  and generalized hyperhidrosis. [ 17 ]


Prescription medications called  anticholinergics , often taken by mouth, are sometimes used in the treatment of both generalized and focal hyperhidrosis. [ 18 ]  Anticholinergics used for hyperhidrosis include  propantheline ,  glycopyrronium bromide  or  glycopyrrolate ,  oxybutynin ,  methantheline , and  benzatropine . Use of these drugs can be limited, however, by side-effects, including dry mouth,  urinary retention , constipation, and visual disturbances such as  mydriasis  and  cycloplegia . For people who find their hyperhidrosis is made worse by anxiety-provoking situations ( public speaking , stage performances, special events such as weddings, etc.), taking an anticholinergic medicine before the event may help. [ 19 ]  In 2018, the U.S.  Food and Drug Administration  (FDA) approved the  topical  anticholinergic  glycopyrronium tosylate  for the treatment of primary axillary hyperhidrosis. [ 20 ] [ 21 ]


For peripheral hyperhidrosis, some people have found relief by simply ingesting crushed ice water. Ice water helps to cool excessive body heat during its transport through the blood vessels to the extremities, effectively lowering overall body temperature to normal levels within ten to thirty minutes. [ 22 ]


Injections of  botulinum toxin  type A can be used to block neural control of sweat glands. The effect can last from 3–9 months depending on the site of injections. [ 23 ]  This use has been approved by the U.S.  Food and Drug Administration  (FDA). [ 24 ]  The duration of the beneficial effect in primary palmar hyperhidrosis has been found to increase with repetition of the injections. [ 25 ]  The Botox injections tend to be painful. Various measures have been tried to minimize the pain, one of which is the application of ice.


This was first demonstrated by Khalaf Bushara and colleagues as the first nonmuscular use of BTX-A in 1993. [ 26 ]  BTX-A has since been approved for the treatment of  severe primary axillary hyperhidrosis  (excessive underarm sweating of unknown cause), which cannot be managed by topical agents. [ when? ] [ 27 ] [ 28 ]


miraDry , a  microwave -based device, has been tried for excessive underarm perspiration and appears to show promise. [ 29 ]  With this device, rare but serious side effects exist and are reported in the literature, such as paralysis of the upper limbs and  brachial plexus . [ 30 ]


Tap water  iontophoresis  as a treatment for palmoplantar hyperhidrosis was originally described in the 1950s. [ 31 ]  Studies showed positive results and good safety with tap water iontophoresis. [ 32 ]  One trial found it decreased sweating by about 80%. [ 33 ]


Sweat gland removal or destruction is one surgical option available for axillary hyperhidrosis (excessive underarm perspiration). There are multiple methods for sweat gland removal or destruction, such as sweat gland suction, retrodermal curettage, and axillary liposuction, Vaser, or Laser Sweat Ablation. Sweat gland suction is a technique adapted for liposuction. [ 34 ]


The other main surgical option is  endoscopic thoracic sympathectomy  (ETS), which cuts, burns, or clamps the thoracic ganglion on the main sympathetic chain that runs alongside the spine. Clamping is intended to permit the reversal of the procedure. ETS is generally considered a "safe, reproducible, and effective procedure and most patients are satisfied with the results of the surgery". [ 35 ]  Satisfaction rates above 80% have been reported, and are higher for children. [ 36 ] [ 37 ]  The procedure brings relief from excessive hand sweating in about 85–95% of people. [ 38 ]  ETS may be helpful in treating axillary hyperhidrosis, facial blushing and facial sweating, but failure rates in people with facial blushing and/or excessive facial sweating are higher and such people may be more likely to experience unwanted side effects. [ 39 ]


ETS side-effects have been described as ranging from trivial to devastating. [ 40 ]  The most common side-effect of ETS is compensatory sweating (sweating in different areas than prior to the surgery). Major problems with compensatory sweating are seen in 20–80% of people undergoing the surgery. [ 41 ] [ 42 ] [ 43 ]  Most people find the compensatory sweating to be tolerable while 1–51% claim that their quality of life decreased as a result of  compensatory sweating ." [ 36 ]  Total body perspiration in response to heat has been reported to increase after sympathectomy. [ 44 ]  The original sweating problem may recur due to nerve regeneration, sometimes as early as 6 months after the procedure. [ 41 ] [ 42 ] [ 45 ]


Other possible side-effects include  Horner's Syndrome  (about 1%),  gustatory  sweating (less than 25%) and excessive dryness of the palms (sandpaper hands). [ 46 ]  Some people have experienced cardiac sympathetic denervation, which can result in a 10% decrease in heart rate both at rest and during exercise, resulting in decreased exercise tolerance. [ 47 ]


Percutaneous sympathectomy is a minimally invasive procedure similar to the botulinum method, in which nerves are blocked by an injection of  phenol . [ 48 ]  The procedure provides temporary relief in most cases. Some physicians advocate trying this more conservative procedure before resorting to surgical sympathectomy, the effects of which are usually not reversible.


Hyperhidrosis can have physiological consequences such as cold and clammy hands, dehydration, and skin infections secondary to maceration of the skin. Hyperhidrosis can also have devastating emotional effects on one's individual life. [ 49 ]


Those with hyperhidrosis may have greater stress levels and more frequent depression. [ 50 ]


Excessive sweating or focal hyperhidrosis of the hands interferes with many routine activities, [ 51 ]  such as securely grasping objects. Some people with focal hyperhidrosis sufferers avoid situations where they will come into physical contact with others, such as greeting a person with a handshake. Hiding embarrassing sweat spots under the armpits limits the affected person's arm movements and pose. In severe cases, shirts must be changed several times during the day and require additional showers both to remove sweat and control body odor issues or microbial problems such as acne, dandruff, or athlete's foot. Additionally, anxiety caused by self-consciousness to the sweating may aggravate the sweating. Excessive sweating of the feet makes it harder for people to wear slide-on or open-toe shoes, as the feet slide around in the shoe because of sweat. [ 52 ]


Some careers present challenges for people with hyperhidrosis. For example, careers that require the use of a knife may not be safely performed by people with excessive sweating of the hands. The risk of  dehydration  can limit the ability of some to function in extremely hot (especially if also humid) conditions. [ 53 ]  Even the playing of musical instruments can be uncomfortable or difficult because of sweaty hands. [ 54 ]


It is estimated that the incidence of focal hyperhidrosis may be as high as 2.8% of the population of the United States. [ 51 ]  It affects men and women equally, and most commonly occurs among people aged 25–64 years, though some may have been affected since early childhood. [ 51 ]  About 30–50% of people have another family member affected, implying a  genetic  predisposition. [ 51 ]


In 2006, researchers at  Saga University  in Japan reported that primary palmar hyperhidrosis maps to gene locus 14q11.2–q13. [ 55 ]


The  Journal of Cardiothoracic Surgery  is an  open access ,  peer-reviewed  online journal that encompasses all aspects of research in  cardiothoracic surgery .The Journal publishes original scientific research related to all domains of cardiac, vascular and thoracic surgery.


1) Editorial Board:  https://cardiothoracicsurgery.biomedcentral.com/about/editorial-board


2) Instruction for Authors:  https://www.biomedcentral.com/about/foreditors


Lung surgery  is a type of  thoracic surgery  involving the repair or removal of  lung  tissue, [ 1 ]  and can be used to treat a variety of conditions ranging from  lung cancer  to  pulmonary hypertension . Common operations include anatomic and nonanatomic resections,  pleurodesis  and  lung transplants . Though records of lung surgery date back to the  Classical Age , new techniques such as  VATS  continue to be developed.


The first written records of lung surgery were provided by  Hippocrates , where he described a treatment for thoracic  empyema  by means of drainage. [ 2 ]  Thoracic procedures became more viable with the advent of  positive pressure ventilation , [ 3 ]  introduced by  Samuel Meltzer  in 1909. This technique enables surgeons to conduct open chest procedures without risking  hypoxia , [ 4 ]  significantly decreasing patient mortality and is presently used in conjunction with  double-lumen endotracheal intubation  to isolate the ventilation of the affected lung during surgery. [ 5 ]  The 20th century saw further innovation of new procedures, such as the first-ever  pneumonectomy  performed by  Evarts Graham  in 1933. [ 6 ]  A breakthrough in minimally invasive lung surgery was also achieved in the form of  thoracoscopy , developed by  Hans Christian Jacobaeus  in 1910 as a method to diagnose  tuberculosis . Thoracoscopy was later used by surgeons to perform chest operations without  open thoracotomy . [ 7 ]  However, the latter remains a widely used method to access the  pleural cavity . [ 8 ]


Before the advent of  tuberculosis chemotherapy  in the 1940s, the disease was treated via collapse therapy. [ 9 ]  This involved the creation of an artificial  pneumothorax , aimed at resting the infected lung to limit infection spread and accelerate healing. The traumatic nature of collapse therapy and the discovery of antituberculosis drugs has rendered the former obsolete. [ 10 ]


Lung cancer can be classified into two main types:  non-small cell lung cancer  (NSCLC) and  small cell lung cancer  (SCLC). NSCLC, the most common of the two types, is a group of cancers including  squamous cell carcinoma ,  adenocarcinoma  and  large cell carcinoma . [ 11 ]  SCLC is highly aggressive and consists of small ovoid cells. [ 12 ]  Surgical resection is used curatively in stage I-III NSCLC and  palliatively  in stage IV. [ 13 ]


A  pneumothorax , also known as a collapsed lung, is a collection of air outside the lung in the pleural cavity. [ 14 ]  Depending on etiology, a pneumothorax is classified as spontaneous, traumatic and  iatrogenic . A spontaneous pneumothorax is further classified as primary and secondary, with the former occurring in individuals with no clinical lung disease and the latter occurring as a complication of preexisting lung disease. [ 15 ]


Chronic obstructive pulmonary disease  (COPD) is a group of diseases that results in airflow blockage and therefore cause breathing-related issues. COPD includes  emphysema  as well as chronic  bronchitis . [ 16 ]


Cystic fibrosis  is a genetic disease, caused by a mutation that results in defects in movement of salt and water in and out of cells which can cause sticky mucus in the body’s tubes and passageways such as in the lungs. [ 17 ]


Pulmonary hypertension  occurs as a result of excess pressure in the blood vessels from the heart to the lungs. An increased amount of muscle in the walls of the blood vessels to the lung is prominent in cases with pulmonary hypertension. Although there are treatments such as  oxygen therapy  and medicine that is given to reduce swelling, lung transplantation may be necessary in some extreme cases. [ 18 ]


Idiopathic pulmonary fibrosis  causes the lungs to become scarred which results in a difficulty in breathing. The causes are of this disease is still not fully known, however, prevention methods include self-care such as stopping smoking and exercising. Medicines such as  pirfenidone  and  nintedanib  are also commonly used in order to reduce the rate of scarring in the lungs. Lung transplantation is effective in certain cases, however this depends on the availability of healthy donor lungs. [ 19 ]


Anatomic resections refer to procedures where a section of the lung is removed with respect to lobar or segmental anatomy. [ 20 ]  These include pneumonectomies, lobectomies and segmentectomies and are commonly used for the treatment of NSCLC. Preoperative evaluations for resections include cancer  staging  via a chest  CT scan  and  PET scan , followed by assessments of pulmonary reserve volume and cardiac function to determine the amount of lung tissue that can be safely removed without developing pulmonary insufficiency. [ 21 ]  Following tissue removal, the resultant bronchial stumps are pressurised under water to check for air leaks before the resection is deemed complete. [ 22 ]


A  pneumonectomy  is the surgical removal of an entire lung. Due to the high morbidity and mortality of the procedure, its viability for treating lung cancer is a subject of debate. [ 23 ]  However, pneumonectomies are still used for lung carcinomas that are large and centrally located or have invaded the interlobar fissures. Another indication for the use this procedure is lung destruction due to chronic infections.


During a pneumonectomy, the pleural cavity is accessed through a  thoracotomy . With direct access to the tumour, the need for pneumonectomy is reassessed. After surgeons decide to proceed with the procedure, the  hilar structures  are dissected sequentially. The pulmonary artery, then the pulmonary veins, are divided via stapling. Next, the main bronchus is divided using a scalpel and the lung is removed from the pleural cavity. The bronchial stump is subsequently closed by  polyglactin   sutures . Finally,  mediastinal  lymph nodes are dissected. [ 22 ]


A  lobectomy  is the surgical removal of one of the five  lung lobes  (right upper, right middle, right lower, left upper and left lower lobes). [ 24 ]  Lobectomies are the most common type of lung surgery and the standard operation for most NSCLC patients. [ 25 ]  Though specific surgical techniques vary for each lobe, the general workflow is identical. The lobe to be resected is first visualized through  thoracotomy  or  thoracoscopy . Next, the surrounding  lymph nodes  are harvested to check for metastasis. After confirmation that no metastasis has taken place, the vasculature of the lobe is controlled by blood vessel division using a  stapler . Stapling is also used to divide the lobar bronchus and subsequently separate the lobe along the lung fissure(s). After the lobe is removed, lymph node dissection is completed.


Specific considerations exist for certain lobes. Right middle lobectomies are not usually carried out alone and are instead part of a bilobectomy alongside a right upper or lower lobectomy. Left upper lobectomies require additional caution to avoid arterial branches from the fissure and proximal  pulmonary artery . [ 21 ]  Another risk is the proximity of the  recurrent laryngeal nerve  to the upper mediastinal lymph nodes, which increases its risk of injury during lymph node dissection. [ 26 ]  Thus, a swallowing study is required if nerve damage is suspected postoperatively. [ 13 ]


A sleeve lobectomy is a lobectomy that is coupled with the removal of a part of the main bronchus. The ends of the bronchus are then rejoined to reattach any remaining lung lobes. [ 27 ]  This procedure is performed in lieu of pneumonectomy when surgeons determine the removal of the entire lung to be unnecessary for centrally located tumours. [ 22 ]


Segmentectomies  are the surgical removal of  bronchopulmonary segments  and often involve the removal of two adjacent segments. The pulmonary arterial branches to the segments are first identified then divided. Next, stapling is used to divide the segmental bronchi and separate the segments from the lung. [ 13 ]  Compared to lobectomies, this procedure has higher survivability for stage 1A patients with tumours ≤ 2 cm in diameter. [ 28 ]


Non-anatomic resections refer to the removal of lung tissue without respect to lobar or segmental anatomy. They can be used to treat a variety of lung diseases such as NSCLC and tuberculosis.


A  wedge resection  is the non-anatomic removal of a triangular-shaped piece of tissue from the lungs. The utility of wedge resection in NSCLC is disputed. Wedge resection is currently used in NSCLC patients with low pulmonary function, or for pulmonary tuberculosis patients with multiple lesions which do not respect intersegmental boundaries. [ 13 ]


A bleb resection is the surgical removal of one or more  blebs , small collections of air between the lung and visceral pleura. Blebs may combine to form larger cysts named bullae. The rupture of blebs or bullae results in air leaking into the pleural space, causing a spontaneous pneumothorax. In most cases, patients will be unaware of blebs until they are detected by CT scans or cause noticeable symptoms such as chest pain. [ 29 ]


Bleb resections may be done via mini-thoracotomy or thoracoscopy. After inspection of the chest cavity, identified blebs are removed via dissection and stapling. To prevent future bleb formation, this procedure is often accompanied by pleurodesis. [ 22 ]


A pneumothorax is commonly treated with needle aspiration of air followed by  chest tube  drainage. In the case of a recurrent pneumothorax,  pleurodesis  may be used to prevent further air accumulation. [ 14 ]