Dana R. Sands

Anal fistula plug: Initial experience and outcomes

PURPOSE: This study was designed to analyze the efficacy of the Cook Surgisis® AFP™ anal fistula plug for the management of complex anal fistulas. METHODS: This was a retrospective review of all patients prospectively entered into a database at our institution who underwent treatment for complex anal fistulas using Cook Surgisis® AFP™ anal fistula plug between July 2005 and July 2006. Patients demographics, fistula etiology, and success rates were recorded. The plug was placed in accordance with the inventors guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. RESULTS: Thirty-five patients underwent 39 plug insertions (22 men; mean age, 46 (range, 15-79) years). Three patients were lost to follow-up, therefore, 36 procedures to be analyzed. The fistula etiology was cryptoglandular in 31 (88.6 percent) patients and Crohns disease associated in the other 4 (11.4 percent). There were 11 smokers and 3 patients with diabetes. The mean follow-up was 126 days (standard = 69.4). The overall success rate was 5 of 36 (13.9 percent). One of the four Crohns disease-associated fistulas healed (25 percent) and 4 of 32 (12.5 percent) procedures resulted in healing of cryptoglandular fistulas. In 17 patients, further procedures were necessary as a result of failure of treatment with the plug. The reasons for failure were infection requiring drainage and seton placement in 8 patients (25.8 percent), plug dislodgement in 3 (9.7 percent), persistent drainage/tract and need for other procedures in 20 patients (64.5 percent). CONCLUSIONS: The success rate for Surgisis® AFP™ anal fistula plug for the treatment of complex anal fistulas was (13.9 percent), which is much lower than previously described. Further analysis is needed to explain significant differences in outcomes.

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.

Do elderly patients benefit from laparoscopic colorectal surgery

BackgroundThe steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients.AimTo analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP).MethodsA retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age ≥ 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality.Results641 patients (M/F – 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 – 60%) than in group B (106/234 – 45%) – p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3–17) days versus 8.7 (4–22) days in group B (p <0.0001), and LAP: 5.3 (2–19) days versus 6.4 (2–34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003).ConclusionsElderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

Prospective Multicenter Trial Comparing Echodefecography With Defecography in the Assessment of Anorectal Dysfunction in Patients With Obstructed Defecation

BACKGROUND: Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations. OBJECTIVE: This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation. DESIGN: Multicenter, prospective observational study. PATIENTS: Women with symptoms of obstructed defecation. SETTING: Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela). INTERVENTIONS: Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans. MAIN OUTCOME MEASURES: The &kgr; statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele. RESULTS: Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6–23); median age, 53.4 (range, 26–77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; &kgr; = 0.61; 95% CI = 0.48–0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (&kgr; = 0.79; 95% CI = 0.57–1.0). Intussusception was associated with rectocele in 28 patients for both methods (&kgr; = 0.62; 95% CI = 0.41–0.83). There was substantial agreement for anismus (&kgr; = 0.61; 95% CI = 0.40–0.81) and for rectocele combined with anismus (&kgr; = 0.61; 95% CI = 0.40–0.82). Agreement for grade III enterocele was classified as almost perfect (&kgr; = 0.87; 95% CI = 0.66–1.0). LIMITATIONS: Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used. CONCLUSIONS: Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

What Are the Outcomes of Reoperative Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis Surgery?

PURPOSE: Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery. METHODS: The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence. RESULTS: Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohns disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohns disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohns disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent. CONCLUSION: Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeons preference and patient-related factors such as diagnosis.

The correlation between tumour regression grade and lymph node status after chemoradiation in rectal cancer

Objective  To determine the correlation between tumour response to preoperative RCTX and lymph node status, an established parameter of clinical outcome.

Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes

BackgroundSolitary rectal ulcer syndrome (SRUS) is a rare disorder often misdiagnosed as a malignant ulcer. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless, the endoscopic and clinical presentations may be confusing. The aim of the present study was to assess the clinical findings, surgical treatment, and outcomes in patients who suffer from SRUS.Materials and methodsA retrospective chart review was undertaken, from January 1989 to May 2005 for all patients who were diagnosed with SRUS. Data recorded included: patient’s age, gender, clinical presentation, past surgical history, diagnostic and preoperative workup, operative procedure, complications, and outcomes.ResultsDuring the study period, 23 patients were diagnosed with SRUS. Seven patients received only medical treatment, and in three patients, the ulcer healed after medical treatment. Sixteen patients underwent surgical treatment. In four patients, the symptoms persisted after surgery. Two patients presented with postoperative rectal bleeding requiring surgical intervention. Three patients developed late postoperative sexual dysfunction. One patient continued suffering from rectal pain after a colostomy was constructed. Median follow-up was 14 (range 2–84) months.ConclusionThe results of this study show clearly that every patient with SRUS must be assessed individually. Initial treatment should include conservative measures. In patients with refractory symptoms, surgical treatment should be considered. Results of anterior resection and protocolectomy are satisfactory for solitary rectal ulcer.

Formalin Instillation for Hemorrhagic Radiation Proctitis

Although formalin instillation has been proven to be an effective treatment of hemorrhagic radiation proctitis, different tech niques with varying success rates have been reported. The aim of this study was to assess our experience with formalin instillation for the treatment of radiation proctitis. After Institutional Review Board approval, all patients who presented with radiation proctitis and were treated with 4% formalin instillation were identified from a prospective database. Techniques of instillation were as follows: a formalin-soaked sponge stick was applied via a proctoscope (SS) and placed at each quadrant with a mean contact of 2.5 minutes (range, 0.5-3 minutes), or the formalin solution was introduced through a proctoscope in aliquots for a total of 350 to 400 mL irrigation (IR), with a mean contact time of 30 seconds in each aliquot. The patients were divided into two groups according to the method of formalin instillation and their outcomes were compared. Between March 1995 and September 2003, 21 patients who underwent formalin treatment were identified: 17 patients were in the SS and 4 patients were in the IR group. The mean age was 74.8 6.4 years and 70.5 6.8 years and the male/female ratio was 16:1 and 3:1 in the SS and IR groups, respectively. Indications for radiation therapy were prostate cancer in 19 patients: 16 (95.1%) SS patients and 3 (75%) IR patients. Four (23.5%) patients in the SS group were receiving anticoagulants or antiplatelet medications before the procedure. The mean duration of bleeding before formalin instillation was 11.7 months (range, 2-48 months) in the SS and 10.5 months (range, 7-12 months) in the IR group. Sixteen (94.1%) patients in the SS and 4 (100%) in the IR group had previous treatments for radiation proctitis, including hydrocortisone enema, 5-aminosalicylate mesalamine, and endoscopic coagulation. Eight (47.1%) patients in the SS and 2 (50%) in the IR group received a preprocedural blood transfusion, and 1 patient in the SS group required a blood transfusion after the formalin instillation. This patient subsequently underwent restorative proctosigmoidectomy because of persistent bleeding. The mean length of the procedure was 27.1 10.8 minutes in the SS group and 22.5 6.5 minutes in the IR group. The bleeding was successfully stopped on the first attempt in 14 patients (82.4%) in the SS group and 3 (75%) in the IR group. The instillation was repeated in 1 patient (5.9%) in the SS group and in 1 (25%) in the IR group. Four patients (23.5%) in the SS group experienced rectal pain after the procedure. One patient (5.9%) developed a new onset of fecal incontinence, while another (5.9%) had anococcygeal pain accompanied by worsening of fecal incontinence. One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months). Formalin instillation is effective in controlling refractory hemorrhage secondary to radiation proctitis.

Perianal Crohn's Disease

Crohns disease is commonly complicated by perianal manifestations. The surgeon plays a pivotal role in caring for these patients; a detailed history along with a thorough clinical exam provides the treating physician with invaluable information upon which to base further investigations and management decisions. Other than abscess drainage, medical management to control proximal disease often precedes any surgical attempt to cure the disease. Surgical interventions are indicated in selective patients, but are often complicated by poor wound healing and recurrences. A sizable percentage of these patients may need a proctectomy.

Nasogastric Tubes and Dietary Advancement After Laparoscopic and Open Colorectal Surgery

Historically, all patients having abdominal procedures routinely awoke with a nasogastric tube, which remained until the resolution of the postoperative ileus as defined by the passage of flatus or feces per rectum. Dietary advancement was accomplished in a stepwise fashion, starting with clear liquids, progressing to full liquids, and finally a regular diet. Recently, the postoperative nutritional management of elective colorectal surgical patients has undergone several modifications and advancements. With the advent of the laparoscopic technique, attention was focused on the reported benefits of decreased postoperative pain, length of ileus, and consequently faster return to tolerance of diet. Surgeons then began to wonder if these benefits were really unique to laparoscopic surgery, or if laparotomy patients were merely treated differently than laparoscopy patients during the postoperative course. The next logical question was whether, after laparotomy, patients could be treated in the same manner as laparoscopic patients and enjoy the same postoperative benefits. The avoidance of a nasogastric tube and hence the subsequent rapid advancement of diet may shorten the length of hospitalization.