Ian Lindsey

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

AbstractPURPOSE: Fibrin glue is a novel treatment for anal fistulas and possesses many advantages in the treatment of difficult high fistulas. Fibrin glue treatment is simple and repeatable; failure does not compromise further treatment options; and sphincter function is preserved. We aimed to compare the outcomes of patients with low and high anal fistulas randomly assigned to either fibrin glue or conventional treatment. METHODS: Patients with simple fistulas (low fistulas) and complex fistulas (high, Crohn’s, and low fistulas with compromised sphincters) were randomly assigned to either fibrin glue or conventional treatment (fistulotomy or loose seton insertion with or without subsequent advancement flap). Patients with rectovaginal fistulas and anal fistulas associated with chronic cavities, acute sepsis, and side branches were excluded. The primary end point was fistula healing. Secondary end points were complications, changes in preoperative continence score, changes in maximum resting and squeeze pressure, satisfaction scores, and pain scores and time off work (simple fistulas only). RESULTS: Patients in the fibrin glue and conventional treatment arms were well matched for gender, median age, duration of fistula symptoms, and follow-up. Fibrin glue healed three (50 percent) of six and fistulotomy seven (100 percent) of seven simple fistulas (difference, 50 percent; confidence interval, 10 to 90 percent; P = 0.06, Fisher’s exact probability test). There was no change in baseline incontinence score, maximum resting pressures, or squeeze pressures between the study arms. Return to work was quicker in the glue arm, but pain scores were similar and satisfaction scores higher in the fistulotomy group. Fibrin glue healed 9 (69 percent) of 13 and conventional treatment 2 (13 percent) of 16 complex fistulas (difference, 56 percent; 95 percent confidence interval, 25.9 to 86.1 percent; P = 0.003, Fisher’s exact probability test). There was no change in baseline incontinence score, maximum resting pressures, or squeeze pressures in either study arm. Satisfaction scores were higher in the fibrin glue group. CONCLUSIONS: No advantage was found for fibrin glue over fistulotomy for simple fistulas, but fibrin glue healed more complex fistulas than conventional treatment and with higher patient satisfaction.

Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results

Objective  Over the last 15 years, posterior rectopexy, which causes rectal autonomic denervation, was discredited for internal rectal prolapse because of poor results. The condition became medical, managed largely by biofeedback. We aimed to audit the short‐term functional results of autonomic nerve‐sparing laparoscopic ventral rectopexy (LVR) for internal rectal prolapse.

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

Objective  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.

Randomized, Double-Blind, Placebo-Controlled Trial of Sildenafil (Viagra®) for Erectile Dysfunction After Rectal Excision for Cancer and Inflammatory Bowel Disease

AbstractPURPOSE: Controlled trials have demonstrated the efficacy of sildenafil for “mixed etiology” erectile dysfunction, but this may not be the case if there is underlying pelvic parasympathetic nerve damage. We aimed to determine the efficacy of sildenafil after rectal excision for rectal cancer and inflammatory bowel disease. METHODS: Patients with erectile dysfunction after rectal excision were randomly assigned in a double-blind manner to sildenafil or placebo groups. After unblinding, placebo patients crossed over to open sildenafil. Primary end points were improvement in erectile function on a global efficacy question and erectile function questionnaire scores. Secondary end points were frequency and severity of side effects. RESULTS: Thirty-two patients were randomly assigned, and two dropped out before randomization. Fourteen received sildenafil, and 18 received placebo. Eleven (79 percent) of 14 responded to sildenafil, on global efficacy assessment, compared with 3 (17 percent) of 18 taking placebo (mean difference, 61.9 percent; 95 percent confidence interval, 34.4 to 89.4 percent; P = 0.0009). Sildenafil improved both erectile function domain scores (mean difference, 13.3; 95 percent confidence interval, 7.9 to 18.7; P = 0.0001) and total International Index of Erectile Function scores (mean difference, 30.6; 95 percent confidence interval, 18.7 to 42.6; P < 0.0001) from pretreatment baseline scores. Placebo did not produce improvement in either erectile function (mean difference, 1.7; 95 percent confidence interval, −0.8 to 4.2; P = 0.16) or total International Index of Erectile Function scores (mean difference, 5; 95 percent confidence interval, −1.1 to 11.1; P = 0.1). Ten (100 percent) of 10 crossover patients not responding to placebo did respond to sildenafil (difference, 100 percent; P < 0.0001). Sildenafil improved both erectile function domain scores (mean difference, 16.8; 95 percent confidence interval, 9.7 to 24; P = 0.002) and total International Index of Erectile Function scores (mean difference, 29.5; 95 percent confidence interval, 15.8 to 43.2; P = 0.003) from precrossover baseline scores. Seven (50 percent) of 14 patients on sildenafil compared with 4 (22 percent) of 18 on placebo experienced side effects (difference, 28 percent; 95 percent confidence interval, −4.4 to 60.4 percent; P = 0.14), 91 percent of which were mild and well tolerated. CONCLUSION: Sildenafil completely reverses or satisfactorily improves postproctectomy erectile dysfunction in 79 percent of patients. Side effects are usually mild and well tolerated. The damage incurred by the pelvic nerves after proctectomy, less profound than after prostatectomy, is likely to result in a partial parasympathetic nerve lesion.

Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete

Aim  Perineal approaches are considered to be the ‘gold standard’ in treating elderly patients with external rectal prolapse (ERP) because morbidity and mortality with perineal approaches are lower compared with transabdominal approaches. Higher recurrence rates and poorer function are tolerated as a compromise. The aim of the present study was to assess the safety of laparoscopic ventral rectopexy (LVR) in elderly patients, compared with perineal approaches.

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

Background  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.

Single-Port Laparoscopic Total Colectomy for Medically Uncontrolled Colitis

PURPOSE: New-generation multi-instrument ports for laparoscopic surgery now allow abdominal surgery via a single-access small incision. Here, we detail how laparoscopic total colectomy can be safely performed within the constraints of such single site operating. METHODS: Three patients (2 males and 1 female; mean age, 28.3 y; mean body mass index, 24.1 kg/m2) requiring urgent total colectomy with end ileostomy for colitis resistant to medical therapy fully consented to have their operation performed by a single-port laparoscopic approach. The single port was placed at the site marked preoperatively for the end ileostomy. The operation commenced with rectosigmoid transection and proceeded with a close pericolic dissection proximally along the colon to the cecum. The resected colon was withdrawn via the port site and the end ileostomy fashioned within this wound. RESULTS: The operation was safely completed in its entirety without additional abdominal access in each case. Mean operative time was 206 minutes. All patients are well with normal stoma appearance and function at a minimum follow-up of 4 months. CONCLUSION: Judicious patient selection and considered operative technique allow major resectional colonic surgery to be safely performed solely by a single-port technique. Proof of clinical benefit along with refined instrumentation is required if such surgery is to progress from anecdotal reports to mainstream practice.

Denonvilliers’ Fascia Lies Anterior to the Fascia Propria and Rectal Dissection Plane in Total Mesorectal Excision

PURPOSEOpinion is divided whether Denonvilliers’ fascia lies anterior or posterior to the anatomic fascia propria plane of anterior rectal dissection in total mesorectal excision. This study was designed to evaluate this anatomic relationship by assessing the presence or absence of Denonvilliers’ fascia on the anterior surface of the extraperitoneal rectum in specimens resected for both nonanterior and anterior rectal cancer in males.METHODSSurgical specimens were collected prospectively from males undergoing total mesorectal excision for mid and low rectal cancer, with a deep dissection of the anterior extraperitoneal rectum to the pelvic floor. Specimens were histopathologically analyzed using best practice methods for rectal cancer. The anterior aspects of the extraperitoneal rectal sections were examined microscopically for the presence or absence of Denonvilliers’ fascia.RESULTSThirty rectal specimens were examined. Denonvilliers’ fascia was present in 12 (40 percent) and absent in 18 specimens (60 percent). Denonvilliers’ fascia was significantly more frequently present when tumor involved (55 percent) rather than spared the anterior rectal quadrant (10 percent; difference between groups 45 percent; 95 percent confidence interval, 30–60 percent; P = 0.024, Fisher’s exact test).CONCLUSIONSWhen tumors were nonanterior, rectal dissection was conducted on fascia propria in the usual anatomic plane, and Denonvilliers’ fascia was not present on the specimen. It was almost exclusively found in anterior tumors, deliberately taken by a radical extra-anatomic anterior dissection in the extramesorectal dissection plane. Denonvilliers’ fascia lies anterior to the anatomic fascia propria plane of anterior rectal dissection and is more closely applied to the prostate than the rectum.