Michael E. Abel

Autologous fibrin glue in the treatment of rectovaginal and complex fistulas.

This nonrandomized series reports the use of autologous fibrin glue to treat complex rectovaginal and anorectal fistulas. The use of an autologous source to prepare fibrin glue eliminates the risk of disease transmission. Ten patients, six women and four men, with complex fistulas were treated with autologous fibrin glue application. Five patients had rectovaginal fistulas; one of them had Crohns disease. Five patients had complex anal fistulas; two of them had Crohns disease, and one had a large postanal ulcer associated with HIV disease. All patients had outpatient preoperative mechanical bowel preparation and prophylactic parenteral antibiotics. Six of the ten patients (60 percent) reported complete healing of the fistulas. Follow-up ranged from three months to one year. Four of five rectovaginal fistulas healed. The two patients with Crohns disease and complex anal fistulas and the patient with HIV disease did not heal, but all three reported significantly less drainage. Autologous fibrin glue is a viable alternative for the treatment of recurrent rectovaginal and complex abscess/fistulas.

Practice parameters for the management of anal fissure. The Standards Task Force American Society of Colon and Rectal Surgeons.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Adenocarcinoma of the Anal Glands Results of a Survey

Anal gland adenocarcinoma is rare, with information concerning this lesion communicated mostly as case reports. Cases seen by authors, combined with a survey of the membership of The American Society of Colon and Rectal Surgeons, allowed 52 cases with sufficient data for analysis. It became clear from the survey that most colorectal surgeons have not treated this malignancy. Predominant symptoms are anal pain (58 percent), rectal bleeding (40 percent), and the presence of perianal mass (37 percent). Fifty-four percent of patients present with a fistula, the incidence of fistula being significantly higher in males. Metastases, which may be inguinal, pelvic, or hepatic, are present at diagnosis in 13.5 percent of patients. Three-fourths of patients are eventually treated by abdominoperineal resection (APR). Twelve percent of the patients in this series had an APR after a failed local excision. The conclusions from this study are: 1) if local excision is attempted, it must be complete, and the patient must be followed closely for many years, and 2) APR is needed in most patients for local control, with the role of subsequent radiation therapy and/or chemotherapy not yet defined.

Parasacrococcygeal approach for the resection of retrorectal developmental cysts

Congenital developmental cysts are the most common retrorectal tumors. Five adult patients, two men and three women, with congenital developmental cysts were operated on via a posterolateral approach through a parasacrococcygeal incision. All wounds healed primarily with no infection or other complications. Recurrent perianal infections and repeated anorectal operations suggest the possibility of retrorectal growths; thus diagnosis requires physician awareness. Computerized tomography is the best preoperative diagnostic test to delineate anatomy and to rule out bony involvement. Because of an infection rate of approximately 30 percent, as well as the presence of symptoms and malignancy in 8 percent of the patients, surgical excision is the treatment of choice. The authors use a posterolateral approach that provides excellent exposure and obviates the need for removal of the coccyx or transection of the sphincter muscle. The authors believe this to be the procedure of choice for excision of retrorectal cystic lesions.

Proctitis following fecal diversion

Nonspecific colitis, histologically similar to ulcerative colitis, may be seen in the defunctionalized colon of patients who have undergone fecal diversion for indications other than inflammatory bowel disease. Little is known about this entity, which may have important diagnostic and therapeutic implications in any patient who undergoes fecal diversion. A case of symptomatic diversion colitis is presented. A review of the records of all patients who underwent fecal diversion in our hospital between 1978 and 1983 yielded one additional patient with asymptomatic colitis in the defunctionalized rectum. Further review of the literature produced only two articles pertaining to diversion colitis, underscoring the lack of recognition of this entity in this group of patients.