Manoj Raval

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

INTRODUCTIONnHigh transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion.nnnMETHODSnThis is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.nnnRESULTSnBetween 1997 and 2008, 232 patients with anal fistula were identified in the St. Pauls Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001).nnnCONCLUSIONSnClosure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.

Impact of short-course radiotherapy and low anterior resection on quality of life and bowel function in primary rectal cancer

BACKGROUNDnShort-course preoperative radiotherapy and total mesorectal excision have decreased local recurrence rates from rectal cancer. However, the effect of this radiotherapy on bowel function and quality of life in these patients is not well understood.nnnMETHODSnBetween 1999 and 2004, 34 patients underwent low anterior resection and either short-course preoperative radiation (N = 24) or surgery alone (N = 10). Quality of life and bowel function were assessed using validated instruments: European Organization of Research and Treatment of Cancer Quality of Life questionnaires, Fecal Incontinence Quality of Life Scale, and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument.nnnRESULTSnPatients treated with preoperative radiation had higher rates of fecal incontinence and showed a strong trend toward lower global quality-of-life scores. In addition, there was a trend toward worse bowel function in these patients.nnnCONCLUSIONSnPatients treated with short-course preoperative radiotherapy had worse continence-related quality of life than patients treated with surgery alone for rectal cancer. Fecal incontinence has a negative effect on quality of life in these patients, causing difficulty with coping, lifestyle, and depression, and limiting daily activities. Validated instruments provide standardized assessment of bowel function and quality of life.

Outcomes of anal fistula surgery in patients with inflammatory bowel disease.

BACKGROUNDnAnal fistulas in patients with Crohns disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion.nnnMETHODSnThis was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively.nnnRESULTSnBetween 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Pauls Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures.nnnCONCLUSIONSnClosure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.

The surgical defect after transanal endoscopic microsurgery: open versus closed management

BackgroundTo determine whether closure of the defect created during full thickness excision of a rectal lesion with transanal endoscopic microsurgery (TEM) leads to fewer complications when compared to leaving the defect unsutured.MethodsThis is a single-center cohort study using a prospectively maintained database. All patients ≥18xa0years old treated with full thickness TEM with no compromise of the peritoneal cavity were included. Two cohorts were established: patients with the defect sutured and patients with the defect left open. Demographic, operative, and pathologic data were compared. The main outcome analyzed was early (<30xa0day postoperative) complications, including bleeding that required investigation and readmission, infection, and reoperation.ResultsBetween 2007 and 2014, data for all patients treated with TEM have been maintained in the St. Paul’s Hospital TEM database. Overall, 236 patients had the TEM defect sutured (TEM-S) and 105 patients had the defect left open (TEM-O). There were no differences between the groups in patient age, gender, tumor size or underlying tumor histology. There was no difference in OR time between the groups, but the most experienced TEM surgeon performed significantly more of the TEM-S procedures (61 vs. 39xa0%, pxa0<xa00.01). There were 40 postoperative complications, affecting 11.7xa0% of the cohort. The complication rate was higher in the TEM-O group (8.4 vs. 19.0xa0%, pxa0=xa00.03). There was no statistically significant difference in bleeding complications (4.7 vs. 7.6xa0%, pxa0=xa00.27) or infections (2.1 vs. 6.7xa0%, pxa0=xa00.05). Readmissions were less common in the TEM-S group (4.7 vs 12.4xa0%, pxa0=xa00.01).ConclusionThe St. Paul’s Hospital TEM experience suggests that while it is safe to leave rectal defects open when a robust mesorectal fat layer is present, there appears to be fewer postoperative complications when the defect is sutured closed.

Outcomes of laparoscopic colon cancer surgery in a population-based cohort in British Columbia: are they as good as the clinical trials?

BACKGROUNDnRandomized controlled trials have shown equivalent outcomes for laparoscopic-assisted colectomy (LAC) and open colectomy (OC) when performed by well-trained surgeons experienced in both techniques. Our goal was to evaluate the outcomes of LAC at a population level.nnnMETHODSnUsing the prospectively collected Gastrointestinal Cancer Outcomes Unit database from the British Columbia Cancer Agency, short- and long-term outcomes in patients with colon cancer treated with LAC and OC were compared from 2003 to 2008 inclusive.nnnRESULTSnThere was a statistically significant increase in the proportion of LAC from 2003 to 2008 (P < .001). LAC was more likely to be performed in the elective setting (P < .001) and for smaller tumors (P < .001). A similar proportion of patients had a minimum of 12 lymph nodes identified by pathology (58% vs 60%, P = not significant). Disease-free survival was similar for the 2 groups after adjusting for stage, emergency presentation, and adjuvant chemotherapy. There was no difference in overall survival.nnnCONCLUSIONSnThe introduction of LAC for colon cancer in British Columbia outside of optimized clinical trial conditions appears to be effective and safe.

Effect of systematic education courses on rectal cancer treatments in a population.

PURPOSEnIn a strategy aimed to improve perioperative and operative management of rectal cancer in British Columbia (BC), a series of educational events were provided for BC surgeons, radiation oncologists, and pathologists including teaching on the use of preoperative radiation, surgical technique with total mesorectal excision (TME), and pathology reporting. Seminars were offered during 2002 and 2003 each over 2 days with documented attendance from 30 hospitals in the province. We wished to determine whether frequency of preoperative radiation and TME surgery changed on a population level after the rectal cancer education courses in 2002 and 2003.nnnMETHODSnAll patients were referred to the BC Cancer Agency, the only center for radiation in BC. Treatments and data were abstracted from the Colorectal Cancer Outcomes Unit database. Patients with resected stage I to III rectal cancer were included who were diagnosed before (2000-2001) and after (2004) the education courses. We used changes from 2000 to 2001 to reflect effects of sporadic continued medical education (CME) compared with effects of formal systematic provincial education courses (changes from 2001 to 2004).nnnRESULTSnA total of 778 eligible patients were included from 2000 (n = 264), 2001 (n = 202), and 2004 (n = 312). The percentage of stage III patients was similar in the 3 time periods. The use of preoperative radiation therapy increased significantly over time, 43% (114/264), 56% (113/202), and 86% (268/312) (P < .0001). TME use also increased significantly, 35%, 44%, and 71% (P < .0001).nnnCONCLUSIONSnThe implementation of guidelines for the use of preoperative radiation and TME by formal systematic provincial education courses for surgeons, radiation oncologists, and pathologists resulted in significant improvements in rectal cancer management on a provincial level. Such programs may be more effective than sporadic CME, particularly in multidisciplinary and complex care settings like adjuvant rectal cancer therapy.

Effects of radiation and surgery on function and quality of life (QOL) in rectal cancer patients

Pre-operative radiotherapy (PRT) and total mesorectal excision surgery (TME) for rectal cancer yield the lowest risk for local recurrence. However, both treatments negatively impact quality of life (QOL). To understand individual treatment effects, we ask whether PRT affects function and quality of life before TME. Function and QOL were prospectively assessed in 26 patients using EORTC QLQ-C30/-CR38, and Wexner scale at three time points: before PRT, 6 weeks after PRT and before TME, and one year after stoma closure. Wexner score did not change post-PRT but did increase post-TME (pu202f<u202f.01). Micturition score did not change with PRT or TME (pu202f=u202f.29). Sexual function score improved post-PRT (pu202f=u202f.03) but did not change post-TME. Global health status did not change post-treatments (pu202f=u202f.45). Future perspective improved post-surgery (pu202f=u202f.04). PRT did not affect micturition, bowel function, or QOL. Future perspective improved despite increased bowel problems and fecal incontinence. QOL was maintained after curative rectal cancer treatments, radiation and TME surgery. This information may help patients and physicians better understand effects of PRT and TME treatments for rectal cancer.

Evaluation of endorectal ultrasound (ERUS) and MRI for prediction of circumferential resection margin (CRM) for rectal cancer

ERUS and MRI are used for preoperative imaging of rectal cancer. Here, we compare ERUS and MRI for accuracy of CRM prediction at mid- and distal rectal locations. In retrospective review, 20 rectal cancer patients having TME surgery had both ERUS and MRI preoperatively: 8 mid rectum and 12 in distal rectum. Predicted CRM by ERUS and MRI were compared to TME pathology. Overall, predicted CRM was 6.5xa0±xa03.6xa0mm by ERUS, 7.7xa0±xa05.0xa0mm by MRI, and 6.0xa0±xa04.6xa0mm by pathology. Overall, correlation coefficients to pathology were 0.77 (pxa0=xa00.0004) for ERUS and 0.64 (pxa0=xa00.008) for MRI. In distal rectum, correlation coefficients were 0.71 (pxa0=xa00.02) for ERUS andxa0-0.10 (pxa0=xa00.79) for MRI. In mid rectum, correlation coefficients were 0.92 (pxa0=xa00.01) for ERUS and 0.44 (pxa0=xa00.38) for MRI. While MRI is used routinely for preoperative rectal cancer imaging, ERUS can provide additional assessment of CRM for mid or distal rectal lesions. Further investigation is needed to support these preliminary ERUS CRM findings in mid and distal rectum.

Salvage TME following TEM: a possible indication for TaTME

BackgroundSalvage surgeryxa0after transanal endoscopic microsurgery (TEM) has shown mixed results. Transanal total mesorectal excision (TaTME) might be advantageous in this population. The aim of this study was to assess the short-term oncologic and operative outcomes of salvage surgeryxa0after TEM, comparing TaTME to conventionalxa0salavge TME (sTME).MethodsConsecutive patients treated with salvage surgery after TEM were identified. Patients who underwent TaTME were compared to those who had conventionalxa0sTME. The primary outcome was the ability to perform an appropriate oncologic procedure defined by a composite outcome (negative distal margins, negative radial margins and complete or near complete mesorectum specimen).ResultsDuring the study period, 41 patients had salvage surgeryxa0after TEM. Of those, 11 patients had TaTME while 30 patients had sTME. All patients in the TaTME group met the composite outcome of appropriate oncologic procedure compared to 76.7% for the conventional sTME group (pu2009=u20090.19). TaTME was associated with significantly higher rates of sphincter preservation (100 vs. 50%, pu2009=u20090.01), higher rates of laparoscopic surgery (100 vs. 23.3%, pu2009<u20090.001) and lower rates of conversion to open surgery (9.1 vs. 57%, pu2009<u20090.001). No difference was found in postoperative morbidity (36.3 vs. 36.7%, pu2009=u20090.77).ConclusionsThe present study demonstrates that for patients requiring salvage surgery after TEM, TaTME is associated with significantly higher rates of sphincter-sparing surgery when compared to conventional transabdominal TME while producing adequate short-term oncologic outcomes. Salvage surgery after TEM might be a clear indication for TaTME rather than conventional surgery.

Peritoneal perforation during transanal endoscopic microsurgery is not associated with significant short-term complications

BackgroundIn patients treated by transanal endoscopic microsurgery (TEM), breach of the peritoneal cavity is a feared intraoperative challenge. Our aim is to analyze predictors and short-term outcomes of patients with peritoneal perforation (TEM-P) when compared to similar patients with no peritoneal compromise (TEM-N).MethodsAt St. Paul’s Hospital, demographic, surgical, pathologic, and follow-up data for all patients treated by TEM is maintained in a prospectively populated database. A retrospective review was performed and two groups were established for comparison: TEM-P and TEM-N. Statistical analysis was performed using student’s t or chi-squared test, where appropriate.ResultsOf 619 patients treated by TEM between 2007 and 2016, 39 (6%) patients were in the TEM-P group and 580 (94%) in the TEM-N group. There were no differences between the groups in patient age, gender, histology, or tumor size. Patients who had peritoneal perforations had more proximal lesions (11 vs. 7xa0cm, pu2009<u20090.0001), anterior lesions (56 vs. 43%, pu2009<u20090.05), and longer operations (80 vs. 51xa0min, pu2009<u20090.005). While most defects were closed endoluminally, 2 patients with perforation were converted to transabdominal surgery. There was a difference in overall hospital stay with TEM-P patients staying on average 2xa0days in hospital with fewer patients managed as day surgery (31 vs. 73%, pu2009<u20090.0001). There were no mortalities or significant 30-day complications in the TEM-P group and only one patient required readmission.ConclusionsThe St. Paul’s Hospital TEM experience suggests patients with peritoneal breach during TEM can be safely managed with outcomes similar to patients without peritoneal entry. Proximal, anterior lesions are at highest risk of peritoneal perforation.