Kunal Kochar

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND: Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement. OBJECTIVE: The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence. DESIGN AND SETTINGS: A retrospective review was performed at 3 university-affiliated teaching hospitals. PATIENTS: All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn’s disease were excluded. MAIN OUTCOME MEASURES: The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed. RESULTS: Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1–125) months. The median time to fistula recurrence was 3 (range, 0–75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Robot-assisted approach to a retrorectal lesion in an obese female

BACKGROUND Often detected incidentally, retrorectal tumors frequently require resection secondary to possibility of malignancy, development of infection, and localized growth with compression. The surgical approach is summarized to abdominal, posterior or a combination, depending on the location of the retrorectal mass and its relationship to the pelvic sidewall. Laparoscopic transabdominal resection of retrorectal tumors has shown safety and efficacy. Robot technology offers a stable platform with superb optics, and endo-wristed instruments that can facilitate dissection in the narrow pelvis. We present the emerging new technique of robot-assisted minimally invasive approach to a retrorectal mass in an obese female. METHODS An obese 35-year-old female, body mass index (BMI) 41 kg/m2, with an incidental 2 cm cystic retrorectal lesion involving the pelvic sidewall was taken to the operating room for a robot-assisted minimally invasive resection of the mass. RESULTS Total operative time was 2 hours and 30 minutes, and total robotic dissection at 70 minutes. The patient was discharged on postoperative day 2. Final pathology revealed a benign Mullerian type cyst, 2.2 cm in greatest dimension. CONCLUSIONS Robot-assisted minimally invasive resection of a retrorectal mass is safe and feasible. This method can be particularly useful in the narrow pelvis and with obese patients.

Redo perineal rectosigmoidectomy with posterior levatorplasty for recurrent rectal prolapse

Rectal prolapse is an uncommon condition mostly affecting the elderly and women populations. Surgical repair is the recommended treatment of choice for those patients who develop full thickness rectal prolapse. The two most common surgical approaches are trans abdominal and perineal. Recurrences of prolapse occur in 5–30% of patients and are higher for perineal approaches. An 83-year-old female with a history of previous Altemeier perineal proctectomy and posterior levatorplasty three years prior presented with recurrent rectal prolapse associated with chronic diarrhea, tenesmus, and mild incontinence. She underwent an uncomplicated redo Altemeier perineal proctosigmoidectomy and posterior levatorplasty. The patient recovered well and was prolapse free at one-year follow-up with significantly reduced associated symptoms. Redo perineal procedures are feasible, similar if not identical to primary resections, and are often easier to perform because the hernia sac is often easily identified. The same principles of perineal primary repair should be used in a redo perineal procedure.

Transanal Excision of Rectal Tumor (TEM or TAMIS)

Transanal surgery encompasses a wide spectrum of surgical techniques ranging from conventional Transanal Excision (TAE), Transanal Endoscopic Microsurgery (TEM), Transanal Minimally Invasive Surgery (TAMIS) to a more recent development of Transanal Total Mesorectal Excision (TATME). TAE was first described by Lisfranc in 1826, and then popularized by Parks in 1960s [1]. Though conventional TAE remains a viable option for benign rectal lesions within 10 cm from anal verge, the use of this technique has been questioned for malignant lesions of the rectum. Transanal excision is widely considered low risk, but complications of bleeding, urinary retention, perforation/fragmentation/recurrence of tumors, anal stenosis, sepsis, and fistulas have been reported.

An Unusual Small Bowel Mass: India Ink Tattooing Mimicking Malignancy

Introduction: India ink is routinely used for preoperative marking of colonic lesions to facilitate identification during laparoscopic colon surgery. It is a relatively inert dye with few reported adverse effects. Case Description: We report a case of inadvertent extracolonic tattooing and intra-peritoneal spillage of India ink leading to adhesions and formation of a mass, which mimicked malignancy. The relevant literature is also reviewed. Discussion: Although India ink is a safe dye for colonic tattooing and most of its complications are asymptomatic, it can occasionally lead to complications that might mimic malignancy and cause a diagnostic dilemma.