Jean-Luc Faucheron

Long-term seton drainage for high anal fistulas in Crohn's disease—A sphincter-saving operation?

METHODS: Forty-one consecutive patients with Crohns disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place. RESULTS: Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two. CONCLUSION: Long-term seton drainage for high anal fistula in Crohns disease is efficacious in both treating sepsis and preserving anal sphincter function.

Doppler-guided hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) for the treatment of grade IV hemorrhoids: long-term results in 100 consecutive patients.

BACKGROUND: Doppler-guided hemorrhoidal artery ligation is a minimally invasive technique for the treatment of symptomatic hemorrhoids that has been applied successfully for grade II and III hemorrhoids but is less effective for grade IV hemorrhoids. Development of a special proctoscope enabled the combination of hemorrhoidal artery ligation with transanal rectoanal repair (mucopexy), which serves to lift and then secure the protruding hemorrhoids in place. OBJECTIVE: The purpose of this study was to describe our experience with this combined procedure in the treatment of grade IV hemorrhoids. DESIGN: Prospective observational study. SETTING: Outpatient colorectal surgery unit. PATIENTS: Consecutive patients with grade IV hemorrhoids treated from April 2006 to December 2008. INTERVENTION: Hemorrhoidal artery ligation–rectoanal repair. MAIN OUTCOME MEASURES: Operating time, number of ligations, number of mucopexies and associated procedures, and postoperative symptoms were recorded. Pain was graded on a visual analog scale. Follow-up was at 2, 6, and 12 months after surgery, and then annually. RESULTS: A total of 100 consecutive patients (64 women, 36 men) with grade IV hemorrhoids were included. Preoperative symptoms were bleeding in 80 and pain in 71 patients; 19 patients had undergone previous surgical treatment for the disease. The mean operative time was 35 (range, 17–60) minutes, with a mean of 9 (range, 4–14) ligations placed per patient. Eighty-four patients were discharged on the day of the operation. Nine patients developed early postoperative complications: pain in 6, bleeding in 4, dyschezia in 1, and thrombosis of residual hemorrhoids in 3. Late complications occurred in 4 patients and were managed conservatively. Recurrence was observed in 9 patients (9%), with a mean follow-up of 34 (range, 14–42) months. LIMITATIONS: The 2 main weaknesses of the study were the lack of very long-term follow-up and the absence of a comparison with hemorrhoidectomy or hemorrhoidopexy. CONCLUSION: Doppler-guided hemorrhoidal artery ligation with rectoanal repair is safe, easy to perform, and should be considered as an effective option for the treatment of grade IV hemorrhoids.

Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: short- and long-term follow-up.

BACKGROUND: There are multiple procedures to treat full-thickness rectal prolapse. No consensus exists as to the best surgical option. All procedures have a significant recurrence rate. OBJECTIVE: The aim of this study was to report short- and long-term technical results following laparoscopic removal of the Douglas pouch peritoneum and anterior rectopexy in patients with total rectal prolapse. DESIGN: This study is a prospective evaluation of consecutive patients. SETTINGS: This investigation was conducted at a single academic colorectal unit. PATIENTS: Between May 1996 and June 2009, 175 consecutive patients (17 males) with a mean age of 58 years (range, 16–94) were operated on. INTERVENTION: The Douglas pouch peritoneum was excised, 2 synthetic meshes were fixated to the anterior part of the lower rectum with five 4-mm staples and to the promontory with 3 spiked chromium staples, and the peritoneum was closed over the meshes to isolate them from the abdominal cavity. MAIN OUTCOME MEASURES: Patients were reviewed at months 1, 6, 12, and then annually. Mortality, morbidity, and recurrence were analyzed. Median follow-up was 74 months (range, 24–181). Recurrence rate was calculated according to the Kaplan-Meier method. RESULTS: There was no mortality. Morbidity (5.1%) consisted in temporary brachial plexus palsy in 2 cases, urinary infection in 3 cases, ureteral lesion in 1 patient having had a previous bone graft on the promontory for spondylolisthesis (JJ catheter), and perforation of the small bowel because of adhesions (laparoscopic suture) in 1 case. One patient presented with a rectal erosion at month 9 (transanal removal of the mesh). Two patients presented with a recurrence of the rectal prolapse at months 6 and 24 (recurrence rate of 3% at 5 years) that was treated with anal artificial sphincter in one and redo operation in the other. CONCLUSION: Laparoscopic removal of the Douglas pouch peritoneum and rectopexy to the promontory is a safe and efficient procedure to treat full-thickness rectal prolapse.

Is fecal continence improved by nonstimulated gracilis muscle transposition

PURPOSE: Gracilis muscle transposition for treatment of fecal incontinence gives variable results. Electric stimulation of transposed muscle recently brought this technique to the surface. METHODS: We reviewed patients who had gracilis muscle transposition for fecal incontinence to determine who might benefit from electrostimulation. RESULTS: Between 1979 and 1991, 22 patients underwent gracilis muscle transposition. At six months, 18 patients had improved continence, but 12 of the 18 were stable with time, and only 1 was fully continent. Six patients were candidates for electrostimulation; four had a contractile but fatigable transposed muscle, and two had ineffective transposed muscle with a gaping nonfibrotic anus. CONCLUSION: Gracilis muscle transposition should be used first for severe incontinent patients, and electrostimulation should be used if there are unsatisfactory results.

Rectal akinesia as a new cause of impaired defecation.

PURPOSE: The aim of this prospective study was to point out a new concept of dyschezia using dynamic videoproctography. METHODS: A total of 154 consecutive patients with impaired defecation prospectively underwent dynamic videoproctography from 1996 to 1998. Evacuation of thick barium of standardized consistency was fully videotaped under fluoroscopy in the sitting position. We measured the weight of barium injected into the rectum (Q1 in g), the weight of barium evacuated (Q2 in g) and the time for rectal evacuation (t in seconds). Flow rate and postdefecation residue were given by calculating Q2/t and (Q1 − Q2)×100/Q1, respectively. We studied all patients whose flow rate and postdefecation residue were less than 5 g/second and more than 30 percent, respectively. These values were arbitrarily chosen, based on rectal evacuation in 25 controls (5 healthy volunteers together with 20 patients without dyschesia). RESULTS: Nine of 154 patients with dyschesia fulfilled the criteria and had none of the usually known causes of dyschezia, such as anismus, megarectum, intussusception, rectal prolapse, rectocele, or enterocele. These nine patients had a normal rectal anatomic appearance and a wide-open short anus but despite exhausting straining efforts were unable to obtain total rectal emptying. Dynamic videoproctography brings strong arguments for an absence of rectal wall contraction, despite normal functioning pelvic floor. CONCLUSIONS: Dynamic videoproctography allows identification of new features in patients with dyschesia: very slow defecation flow rate and high postdefecation residue. This new concept could be called rectal akinesia by analogy with bladder akinesia in some dysuric patients.

Sacral nerve stimulation for fecal incontinence: causes of surgical revision from a series of 87 consecutive patients operated on in a single institution.

PURPOSE: Sacral nerve stimulation is offered to patients presenting with fecal incontinence of neurological or idiopathic etiology, when medical management has failed. The purpose of this study was to investigate the causes of surgical revision following sacral nerve stimulation in consecutive patients who had received implants. PATIENTS AND METHODS: From September 2001 to August 2009, 123 patients (105 women) of mean age 56 years were operated on for neurological (n = 104) or idiopathic (n = 19) fecal incontinence. The mean preoperative Cleveland Clinic score was 13/20 (range 6/20 to 19/20). Eighty-seven patients of 123 had a positive test and underwent stimulator implantation. Any stimulator dysfunction was prospectively studied. RESULTS: Among the 87 patients, 36 had surgical revision of the device for the following reasons: device-related failure due to infection in 4 (successful reimplant in 4), electrode displacement in 2, electrode breakage in 2 (reimplantation of electrode in 4), and dysfunction owing to impedance increase of the system in 4; adverse stimulation with pain in 7 (stimulator repositioning in 4 and explantation in 3); battery depletion either spontaneously (n = 6) or owing to a MRI examination (n = 2); total or partial loss of clinical efficacy in 9 (removal of the generator and electrode). CONCLUSION: Sacral nerve stimulation is a recognized treatment for fecal incontinence. The stimulator reoperation rate is high and is caused by stimulator dysfunction in 24% of cases.

Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results

AIM To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse. METHODS MEDLINE, PubMed, EMBASE, and other relevant database were searched to identify studies. Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review. RESULTS Twelve non-randomized case series studies with 574 patients were included in the review. No surgical mortality was described. Conversion was needed in 17 cases (2.9%), most often due to difficult adhesiolysis. Twenty eight patients (4.8%) presented with major complications. Seven (1.2%) mesh-related complications were reported. Most frequent complications were urinary tract infection and urinary retention. Mean recurrence rate was 4.7% with a median follow-up of 23 mo. Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%. Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages. Evaluation of functional score was disparate between studies. CONCLUSION Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.

Neuromodulation for fecal and urinary incontinence: functional results in 57 consecutive patients from a single institution.

BACKGROUND: Sacral nerve stimulation is a recognized treatment for fecal and urinary incontinence. Few articles have been published about patients presenting with both types of incontinence. OBJECTIVE: The aim of this study was to report the functional results in patients operated on for simultaneous fecal and urinary incontinence by the use of sacral nerve stimulation. DESIGN: This study is a retrospective analysis of prospectively collected data. SETTINGS: The investigation was conducted in the academic departments of colorectal surgery and urology. PATIENTS: Between January 2001 and March 2010, 57 consecutive patients (54 women) with a mean age of 58 years (range, 16–76) were included. INTERVENTIONS: Two-stage sacral nerve modulation (test and implant) was performed. MAIN OUTCOME MEASURES: Functional study before testing, at 6 months, and at the end of follow-up after implantation included the use of the Cleveland Clinic incontinence score, Urinary Symptoms Profile, Fecal Incontinence Quality of Life score, and the Ditrovie score. Patient satisfaction with the technique was evaluated at a median follow-up of 62.8 months. RESULTS: Fecal incontinence improved from 14.1/20 to 7.2/20 at 6 months and 6.9/20 at the end of follow-up. Urinary incontinence, mainly urge incontinence (47% of patients), and urgency frequency (34% of patients) improved at 6 months and end of follow-up, but not retention and dysuria. Specific quality of life was improved for fecal and urinary incontinence at 6 months and end of follow-up. At the end of follow-up, 73% patients were highly satisfied with the technique, but 9% felt their condition had deteriorated. The reoperation rate was 29%, of which 12% were indicated because of a complication. LIMITATIONS: This study was limited by its retrospective nature and the multiple causes of incontinence. CONCLUSION: Fecal and urinary incontinence, studied by symptoms scores and specific quality-of-life scores, are improved in patients receiving sacral nerve stimulation for double incontinence.

Laparoscopic Rectosigmoid Resection With Transanal Colonic Pull-Through and Delayed Coloanal Anastomosis: A New Approach to Adult Hirschsprung Disease

BACKGROUND: Hirschsprung disease in adults is a rare and frequently misdiagnosed cause of long-standing, refractory constipation. Surgical procedures initially developed for pediatric patients have been applied to adults with varying degrees of success. OBJECTIVE: Our aim was to describe a new surgical procedure consisting of laparoscopic rectosigmoid resection with a transanal colonic pull-through followed by a delayed coloanal anastomosis for the treatment of Hirschsprung disease in adults and to present our preliminary results with this technique. DESIGN AND SETTING: This was a descriptive observational study of treatment outcome conducted at the colorectal surgical unit of a university teaching hospital in France. PATIENTS: Patients were adults with confirmed Hirschsprung disease treated from October 2006 through February 2009. INTERVENTION: Laparoscopic rectosigmoid resection was performed with a transanal colonic pull-through followed by a delayed coloanal anastomosis. MAIN OUTCOME MEASURES: Clinical and functional data (Cleveland Clinic Florida incontinence scale and Fecal Incontinence Quality of Life scale) were obtained at postoperative visits. RESULTS: Five patients underwent the procedure. One patient died of postoperative cardiovascular complications. No patient had to be reoperated. No anastomotic leakage occurred. One patient developed anastomotic stricture requiring dilatation. No sexual or urinary dysfunction was reported. Postoperative analysis (mean follow-up 16 months) showed good functional outcomes in 3 (75%) of the 4 evaluable patients. LIMITATIONS: This study had only a small number of patients and no controls other comparison with cases reported in the literature. CONCLUSION: Laparoscopic rectosigmoid resection with a transanal colonic pull-through followed by delayed coloanal anastomosis represents a valid alternative in the treatment of Hirschsprung disease in adult patients, because it involves minimally invasive surgery, does not require a preventive diverting stoma, and shows anastomotic security.

A New Ileal Pouch Salvage Technique

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the surgical treatment of ulcerative colitis. Fistulas originating from the ileal pouch are uncommon but serious complications, sometimes leading to failure of the operation. We describe a technique to treat and salvage a pouch involved in a chronic fistulating ileal J-pouch-anal anastomosis by disconnecting the pouch, turning it inside out after repair, and reanastomosing it to the dentate line.