C. Cunningham

A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula.

AbstractPURPOSE: Fibrin glue is a novel treatment for anal fistulasnand possesses many advantages in the treatment of difficultnhigh fistulas. Fibrin glue treatment is simple and repeatable;nfailure does not compromise further treatment options; andnsphincter function is preserved. We aimed to compare thenoutcomes of patients with low and high anal fistulas randomlynassigned to either fibrin glue or conventional treatment.nMETHODS: Patients with simple fistulas (low fistulas)nand complex fistulas (high, Crohn’s, and low fistulas withncompromised sphincters) were randomly assigned to eithernfibrin glue or conventional treatment (fistulotomy or loosenseton insertion with or without subsequent advancementnflap). Patients with rectovaginal fistulas and anal fistulasnassociated with chronic cavities, acute sepsis, and sidenbranches were excluded. The primary end point was fistulanhealing. Secondary end points were complications, changesnin preoperative continence score, changes in maximumnresting and squeeze pressure, satisfaction scores, and painnscores and time off work (simple fistulas only). RESULTS:nPatients in the fibrin glue and conventional treatment armsnwere well matched for gender, median age, duration ofnfistula symptoms, and follow-up. Fibrin glue healed threen(50 percent) of six and fistulotomy seven (100 percent) ofnseven simple fistulas (difference, 50 percent; confidenceninterval, 10 to 90 percent; P = 0.06, Fisher’s exact probabilityntest). There was no change in baseline incontinencenscore, maximum resting pressures, or squeeze pressuresnbetween the study arms. Return to work was quicker in thenglue arm, but pain scores were similar and satisfactionnscores higher in the fistulotomy group. Fibrin glue healed 9n(69 percent) of 13 and conventional treatment 2 (13 percent)nof 16 complex fistulas (difference, 56 percent; 95npercent confidence interval, 25.9 to 86.1 percent; P = 0.003,nFisher’s exact probability test). There was no change in baselinenincontinence score, maximum resting pressures, ornsqueeze pressures in either study arm. Satisfaction scores werenhigher in the fibrin glue group. CONCLUSIONS: No advantagenwas found for fibrin glue over fistulotomy for simple fistulas,nbut fibrin glue healed more complex fistulas than conventionalntreatment and with higher patient satisfaction.

Preoperative chemoradiotherapy and total mesorectal excision surgery for locally advanced rectal cancer: Correlation with rectal cancer regression Grade

PURPOSEPreoperative long-course chemoradiotherapy is recommended for rectal carcinoma when there is concern that surgery alone may not be curative. Downstaging of the tumor can be measured as rectal cancer regression grade (1-3) and may be of importance when estimating the prognosis. The aim of this study was to look at the long-term results of tumor regression in patients receiving long-course chemotherapy before surgical resection of rectal cancer.METHODSWe reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinoma of the mid rectum or distal rectum found to be stage T3/4 between January 1995 and November 1999. Patients received 45 to 50 Gy irradiation in 2-Gy fractions and an infusion of 5-fluorouracil. Surgical specimens were assessed for rectal cancer regression grade. Patients were followed up routinely with clinical examination, computed tomography, and colonoscopy.RESULTSSixty-five patients with a mean age 65 (range, 32–83) years underwent chemoradiotherapy before surgical resection. Thirty patients (46 percent) were classified as rectal cancer regression Grade 1, with 9 patients (14 percent) having complete sterilization of the tumor. Fifty-three patients (82 percent) underwent a curative resection. Overall survival, with a median follow-up of 39 (range, 24–83) months, was 67 percent and was associated with tumor downstaging. The local recurrence rate was 5.8 percent in those patients who underwent a curative resection and was significantly lower with rectal cancer regression Grade 1 tumors (P = 0.03). Eight of nine patients (89 percent) whose tumor had been sterilized were alive and well with no recurrence of tumor at a median follow-up of 41 (range, 24–70) months.CONCLUSIONSPreoperative chemoradiotherapy resulted in significant regression of tumor. Overall survival was high and was associated with downstaging of tumor. The local recurrence rate was significantly lower with rectal cancer regression Grade 1 tumors and was not seen in patients with sterilized tumors.

The management and outcome of anastomotic leaks in colorectal surgery

Purposeu2002 Anastomotic leaks in colorectal surgery are associated with significant morbidity and mortality and may result in poor functional and oncological outcomes. Diagnostic difficulties may delay identification and appropriate management of leaks. The aim of this study was to look at the diagnosis, clinical management and outcomes of anastamotic leaks in our department.

Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation

Objectiveu2002 Abdominal rectopexy is ideal for otherwise healthy patients with rectal prolapse because of low recurrence, yet after posterior rectopexy, half of the patients complain of severe constipation. Resection mitigates this dysfunction but risks a pelvic anastomosis. The novel nerve‐sparing ventral rectopexy appears to avoid postero‐lateral rectal dissection denervation and thus postoperative constipation. We aimed to evaluate our functional results with laparoscopic ventral rectopexy.

Chronic Anal Fissure

The treatment of chronic anal fissure has shifted in recent years from surgical to medical.

Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study

Backgroundu2002 The aetiology of faecal incontinence is multifactorial, yet there remains an approach to assessment and treatment that focusses on the sphincter. Rectal intussusception (RI) is underdiagnosed and manifests primarily as obstructed defecation. Yet greater than 50% of these patients admit to faecal incontinence on closer questioning. We aimed to evaluate the incidence of RI at evacuation proctography selectively undertaken in the evaluation of patients with faecal incontinence.

Fissurectomy-Botulinum Toxin: A Novel Sphincter-Sparing Procedure for Medically Resistant Chronic Anal Fissure

BACKGROUNDBotulinum toxin heals only approximately one-half of glyceryl trinitrate-resistant chronic anal fissures, perhaps because chemical sphincterotomy alone treats internal sphincter spasm but not chronic fissure fibrosis. We aimed to assess whether a novel procedure, fissurectomy–botulinum toxin, improves the healing rate of medically resistant fissures over that achieved with botulinum toxin alone.METHODSA prospective pilot study of chronic fissure patients failing medical therapy was undertaken. Fissurectomy was performed, with excision of the fibrotic fissure edges, curetting of the fissure base, and excision of the sentinel pile if present. Twenty-five units of botulinum toxin (Botox™) were injected into the internal sphincter. The primary end point was fissure healing, and secondary end points were improvement in symptoms, need for lateral internal sphincterotomy, and side effects.RESULTSThirty patients underwent fissurectomy–botulinum toxin (57 percent female; median age, 39 years). Nineteen patients had failed glyceryl trinitrate, whereas 11 had failure of both glyceryl trinitrate and botulinum toxin. At a median of 16.4 weeks follow-up, 28 fissures (93 percent) were healed. Two fissures (7 percent) remained unhealed but were symptomatically better and avoided lateral internal sphincterotomy. Two patients (7 percent) experienced transitory flatus incontinence.CONCLUSIONFissurectomy–botulinum toxin heals over 90 percent of fissures resistant to medical therapy. Fissurectomy–botulinum toxin allows patients with medically resistant fissures to achieve a high rate of healing while avoiding the risk of incontinence associated with lateral internal sphincterotomy.

Patterns of Fecal Incontinence After Anal Surgery

PURPOSEConservative anal surgery, with maximum preservation of the anal sphincters and continence, is becoming increasingly possible with the emergence of new sphincter-sparing treatments. Many surgeons remain skeptical, however, of the nature and impact of incontinence after anal surgery. We aimed to characterize the patterns of anal sphincter injury in patients with fecal incontinence after anal surgery.METHODSWe reviewed our fecal incontinence database and studied a subset developing incontinence after anal surgery. Maximum resting and squeeze pressures and the distal high-pressure zone to mid–anal canal resting pressure gradient were evaluated. Anal ultrasounds were evaluated and specific postoperative lesions were characterized.RESULTSPatterns of sphincter injury in 93 patients with fecal incontinence after manual dilation, internal sphincterotomy, fistulotomy, and hemorrhoidectomy were studied. The internal sphincter was almost universally injured, in a pattern specific to the underlying procedure. One-third of patients had a related surgical external sphincter injury. Two-thirds of women had an unrelated obstetric external sphincter injury. The distal resting pressure was typically reduced, with reversal of the normal resting pressure gradient of the anal canal in 89 percent of patients. Maximum squeeze pressure was normal in 52 percent.CONCLUSIONIncontinence after anal surgery is characterized by the virtually universal presence of an internal sphincter injury, which is distal in the high-pressure zone, resulting in a reversal of the normal resting pressure gradient in the anal canal. These data support concerns that non–sphincter-sparing anal surgery leads to fecal incontinence and is increasingly difficult to justify given the availability of modern sphincter-sparing approaches.

Botulinum Toxin as Second-Line Therapy for Chronic Anal Fissure Failing 0.2 Percent Glyceryl Trinitrate

AbstractPURPOSE: Glyceryl trinitrate paste is used by many as first-line therapy for chronic anal fissure but heals only approximately 50 to 60 percent of fissures. We use botulinum toxin as second-line therapy after failed glyceryl trinitrate and aimed to evaluate efficacy, side effects, and patient preference. nMETHODS: A prospective, nonrandomized, open-label study of patients with chronic anal fissure failing a course of glyceryl trinitrate treated with 20 units of botulinum toxin A injected into the internal sphincter was conducted. Symptomatic relief, visual healing of fissures, side effects, and patient preference were assessed at 8-week follow-up. nRESULTS: Forty patients underwent botulinum toxin treatment. Twenty-nine patients (73 percent) overall were improved symptomatically and avoided surgery. Seventeen fissures (43 percent) were healed, whereas 23 fissures (57 percent) remained unhealed. Of the unhealed fissures, 5 (12 percent) were asymptomatic, 7 (18 percent) were symptomatically much improved, and 11 (27 percent) were no better symptomatically and came to surgery. Discomfort associated with injection was minimal. Of 34 patients undergoing botulinum toxin injection in the clinic, 24 (71 percent) preferred botulinum toxin, 7 glyceryl trinitrate (20 percent; difference = 51 percent; 95 percent confidence interval = 31–71 percent), and 9 percent were undecided. Transient minor incontinence symptoms were noted in 7 patients (18 percent). nCONCLUSIONS: Second-line botulinum toxin injection improves symptoms in approximately three-quarters of patients after failed primary glyceryl trinitrate therapy and at least in the short term avoids surgical sphincterotomy. Botulinum toxin heals approximately one-half of these fissures. Discomfort and side effects were minimal. A policy of first-line glyceryl trinitrate/second-line botulinum toxin will avoid sphincterotomy in 85 to 90 percent. Higher rates of healing may be achieved by giving botulinum toxin as first-line therapy, or addressing the chronic fibrotic nature of the fissure.

Transanal glove port is a safe and cost-effective alternative for transanal endoscopic microsurgery.

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of rectal tumours that avoids conventional pelvic resectional surgery along with its risks and side‐effects. Although appealing, the associated cost and complex learning curve limit TEM utilization by colorectal surgeons. Single‐port laparoscopic principles are being recognized as transferable to transanal work and hybrid techniques are in evolution. Here the clinical application of a new technique for transanal access is reported.