Dan Ruiz

Gracilis Muscle Interposition for the Treatment of Rectourethral, Rectovaginal, and Pouch-vaginal Fistulas : Results in 53 Patients

Background:The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. Material and Methods:A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). Results:Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1–4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohns disease-associated fistulas successfully healed; 75% without Crohns successfully healed. Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1–3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. Conclusion:The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Comparison of four energy-based vascular sealing and cutting instruments: A porcine model

AimTo compare the safety and efficacy of four energy-based vascular sealing and cutting instruments.MethodsBlood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE™ (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure™ V and LigaSure Atlas™ (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal™ vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury.ResultsThe bursting pressures were significantly higher with EnSeal™ compared to all other instruments (p < 0.0001). The sealing process was significantly shorter with Harmonic ACE™ and significantly longer with LigaSure Atlas™ (p <0.0001). The mean seal width was larger with the LigaSure Atlas™ compared to the other instruments, and it was smaller with EnSeal™ and Harmonic ACE™. Less radial adventitial collagen denaturation was present with EnSeal™ and LigaSure™ V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas™ than with the other instruments; however, the numbers were too small for statistical analysis.ConclusionsThe bursting pressures with EnSeal™ were significantly higher than with all the other instruments. Harmonic ACE™ was the fastest sealing instrument and LigaSure Atlas™ was slowest. EnSeal™ created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas™ created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

The effect of colorectal surgery in female sexual function, body image, self-esteem and general health: a prospective study.

Objective:To evaluate womens sexual function, self-esteem, body image, and health-related quality of life after colorectal surgery. Summary Background Data:Current literature lacks prospective studies that evaluate female sexuality/quality of life after colorectal surgery using validated instruments. Methods:Sexual function, self-esteem, body image, and general health of female patients undergoing colorectal surgery were evaluated preoperatively, at 6 and 12 months after surgery, using the Female Sexual Function Index, Rosenberg Self-Esteem scale, Body Image scale and SF-36, respectively. Results:Ninety-three women with a mean age of 43.0 +/− 11.6 years old were enrolled in the study. Fifty-seven (61.3%) patients underwent pelvic and 36 (38.7%) underwent abdominal procedures. There was a significant deterioration in overall sexual function at 6 months after surgery, with a partial recovery at 12 months (P = 0.02). Self-esteem did not change significantly after surgery. Body image improved, with slight changes at 6 months and significant improvement at 12 months, compared with baseline (P = 0.05). Similarly, mental status improved over time with significant improvement at 12 months, with values superior than baseline (P = 0.007). Physical recovery was significantly better than baseline in the first 6 months after surgery with no significant further improvement between 6 and 12 months. Overall, there were no differences between patients who had abdominal procedures and those who underwent pelvic dissection, except that patients from the former group had faster physical recovery than patients in the latter (P = 0.031). When asked about the importance of discussing sexual issues, 81.4% of the woman stated it to be extremely or somewhat important. Conclusion:Surgical treatment of colorectal diseases leads to improvement in global quality of life. There is, however, a significant decline in sexual function postoperatively. Preoperative counseling is desired by most of the patients.

Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up?

PURPOSE: Fecal incontinence is a socially isolating disease that causes physical and psychologic distress. Radiofrequency delivered to the anal canal is a surgical modality for fecal incontinence that has been noted to be safe and potentially effective. The aim of this study was to evaluate improvement in fecal incontinence and quality of life after the radiofrequency procedure at 1-year follow-up. METHODS: After institutional review board approval, patients with fecal incontinence for at least 3 months were prospectively recruited between March 2003 and June 2004. Patients enrolled in the study underwent the Secca procedure. The Cleveland Clinic Florida Fecal Incontinence Score and the Fecal Incontinence Quality of Life Questionnaire were completed at the first visit and then at 12-month follow-up. Wilcoxon signed rank test was used to analyze the difference between baseline and follow-up. RESULTS: A total of 24 patients (23 females) were enrolled in the study, and 16 were available at the 12-month follow-up visit. The main causes of fecal incontinence were either idiopathic or included obstetric injury, aging, and trauma from previous anorectal surgeries. The mean operative time was 45.5 ± 8.3 minutes, and the mean number of radiofrequency lesions in the anal canal was 65.5 ± 13.8. There were 3 self-limited episodes of postoperative bleeding and 1 instance of constipation that was resolved with laxatives. There were no delayed complications. The mean Cleveland Clinic Florida Fecal Incontinence Score improved from a mean of 15.6 (± 3.2) at baseline to 12.9 (± 4.6) at 12 months (P = .035). The mean Fecal Incontinence Quality of Life Questionnaire score improved in all subsets except for the depression subscore. CONCLUSION: Radiofrequency is a safe, minimally invasive tool for treating patients with fecal incontinence. Improvement in fecal incontinence and quality of life was maintained at 12 months without delayed morbidity. The actual significance of this improvement is yet to be determined.

Graciloplasty for rectourethral, rectovaginal and rectovesical fistulas: technique overview, pitfalls and complications

This technical note describes the surgical technique of graciloplasty as an option for the treatment of rectovaginal, rectourethral and rectovesical fistulas.

Laparoscopic Stoma Construction and Closure

Laparoscopic stoma construction is an option when a stoma for fecal diversion is desired. This chapter describes the indications, contraindications, technique, and tactics for avoiding complications. It also describes techniques for laparoscopic closure of stomas.