Emmanuel G. Balcos

Endorectal advancement flap for treatment of simple rectovaginal fistula

An endorectal advancement flap technique has been utilized in 35 women for repair of “simple” rectovaginal fistulas,i.e., those of low or midseptal location, less than 2.5 cm in diameter, and of traumatic or infectious etiology. Colostomy is unnecessary. Concomitant sphincteroplasty for correction of associated anal incontinence is readily accomplished. Results are excellent with healing ultimately achieved in 32 of 35 women (91 per cent).

Ileal pouch vaginal fistulas: Incidence, etiology, and management

Some of the initial problems associated with the ileonal reservoir have been solved. In their place, other complications have been recognized. Among these, the ileal pouch vaginal fistula stands out as a recently recognized difficult management problem. This multicenter study was undertaken to gain insight into the causes for, and treatment of, pouch vaginal fistulas. Cases were gathered from 11 surgical practices, throughout North America, in which the ileoanal reservoir procedure is frequently performed. Overall, 304 females had undergone ileoanal reservoir procedures by these surgical groups. Twenty-one patients developed 22 pouch vaginal fistulas for an overall incidence of 6.9 percent. Five additional patients with pouch vaginal fistulas, whose restorative proctocolectomies were done elsewhere, were referred to these surgeons for treatment. The courses of these 26 patients form the basis of this report. This study details the risk factors which predispose to the development of a pouch vaginal fistula, as well as the various treatment options available.

Sphincteroplasty for acquired anal incontinence

T H E LOSS Of voluntary control of flatus or feces is a most distressing and incapacitat ing condition. Al though it does not directly threaten health, it is a source o f continued embarrassment and social ostracism to the afflicted individual and to those about him. Loss of fecal continence may vary widely from minimal loss of flatus only, to complete loss of control of all gas, liquids, and solids. T h e purpose of this paper is to present a technique for repair of damaged sphincter muscles used in 37 consecutive patients in the last 23 years.

Is subtotal colectomy a viable option in the management of chronic constipation

To determine if subtotal colectomy constitutes a valuable alternative in the treatment of patients with chronic constipation, a retrospective review of 52 consecutive patients who underwent subtotal colectomy between January 1980 and August 1985 was undertaken. Forty-six patients underwent ileodistal sigmoidostomy while five patients underwent ileoproctostomy and five with concomitant rectal prolapse underwent simultaneous proctopexy. A mortality rate of 3.8 percent and morbidity rate of 60 percent were encountered. The most frequently occurring complication was small-bowel obstruction, which occurred in 36 percent, and necessitated laparotomy in 66 percent. Additional procedures were necessary in five patients because of newly discovered rectal prolapse (two patients), rectocele (one patient), unrelieved constipation (one patient), and incapacitating incontinence (one patient). Follow-up data available in 94 percent (mean, 46 months) disclosed that patients had an average of 2.8 bowel movements per day without the use of laxatives (89 percent) or enemas (80 percent). Overall, 79 percent were satisfied with the final outcome. It is concluded that subtotal colectomy constitutes a viable option in the treatment of chronic constipation. However, the significant morbidity and mortality associated with the procedure dictate the need for careful patient selection on the basis of appropriate physiologic testing.

Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis

An initial experience with a technique of restorative proctocolectomy utilizing a rectal mucosectomy, total colectomy, and ileal reservoir (Parks S-pouch) with ileoanal anastomosis for patients with ulcerative colitis and familial polyposis is presented. Although there were no deaths, significant morbidity did occur and was attributed to the use of a temporary loop ileostomy which may not be necessary. Early functional results are promising and to date, patient satisfaction is very high.

Surgical management of large villous tumors of the rectum.

SummarySeventy-two patients with villous tumors of the rectum were included in the study (Table 2). The tumors ranged from 2 to 12 cm in greates dimension and were 4 to 15 cm from the anal verge. Fifty-three patients had transanal excision of the lesions as a definitive treatment. The surgical technic is described. In three cases abdominoperineal resection was done for invasive carcinoma, and similar radical surgery was necessary for two extensive benign tumors which involved the entire circumference of the rectal wall.Of the 53 villous tumors removed by transanal excision, 34 were reported by the pathologist to be benign, and 19 showed superficial adenocarcinoma, with no microscopic evidence of invasion on serial sections. These tumors with carcinomain situ were considered clinically benign. The longest follow-up period was 10 1/4 years. Five patients had recurrences, two to six years after operation. None of these necessitated radical surgery. Transanal excision of clinically benign villous tumors of the rectum is considered adequate definitive treatment.

Abdominoperineal resection for recurrent cancer following anterior resection

Cases are reviewed of 12 patients who had abdominoperineal resections for cancer recurrence subsequent to anterior resection. Although this procedure is technically more difficult, we experienced no mortality or significant morbidity, and the postoperative hospital stay was similar to that of patients who received an abdominoperineal resection as a primary procedure. Although we have no long-term cures, at least significant palliation can be achieved in selected patients who have no evidence of distant metastases

Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices

Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1)coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy.