Michael J. Snyder

The surgisis® AFP™ anal fistula plug: Report of a consensus conference

A Consensus Conference was held in Chicago on 27th May 2007 at the Illinois Airport Hilton Hotel to develop uniformity of opinion from surgeons with considerable experience in the use of the Anal Fistula Plug. Of the 15 surgeons in attendance, five had performed 50 or more Anal Fistula Plug procedures. Success rates with this approach have been reported to be as high as 85% [1]. Anecdotal communications have however suggested lower rates of success. Concerns have been expressed over plug extrusion and inadequacy of long-term followup. It was thought prudent to hold this conference because, despite a number of publications attesting to the safety and efficacy of the procedure, to date there has not been uniformity of opinion regarding indications and technique, nor has there been level I evidence of any actual benefit.

Prospective multicenter study of a synthetic bioabsorbable anal fistula plug to treat cryptoglandular transsphincteric anal fistulas.

BACKGROUND: Although interest in sphincter-sparing treatments for anal fistulas is increasing, few large prospective studies of these approaches have been conducted. OBJECTIVE: The study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug. DESIGN: A prospective, multicenter investigation was performed. SETTING: The study was conducted at 11 colon and rectal centers. PATIENTS: Ninety-three patients (71 men; mean age, 47 years) with complex cryptoglandular transsphincteric anal fistulas were enrolled. Exclusion criteria included Crohn’s disease, an active infection, a multitract fistula, and an immunocompromised status. INTERVENTION: Draining setons were used at the surgeon’s discretion. Patients had follow-up evaluations at 1, 3, 6, and 12 months postoperatively. MAIN OUTCOME MEASURES: The primary end point was healing of the fistula, defined as drainage cessation plus closure of the external opening, at 6 and 12 months. Secondary end points were fecal continence, duration of drainage from the fistula, pain, and adverse events during follow-up. RESULTS: Thirteen patients were lost to follow-up and 21 were withdrawn, primarily to undergo an alternative treatment. The fistula healing rates at 6 and 12 months were 41% (95% CI, 30%–52%; total n = 74) and 49% (95% CI, 38%–61%; total n = 73). Half the patients in whom a previous treatment failed had healing. By 6 months, the mean Wexner score had improved significantly (p = 0.0003). By 12 months, 93% of patients had no or minimal pain. Adverse events included 11 infections/abscesses, 2 new fistulas, and 8 total and 5 partial plug extrusions. The fistula healed in 3 patients with a partial extrusion. LIMITATIONS: The study was nonrandomized and had relatively high rates of loss to follow-up. CONCLUSION: Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure.

Ambulatory anorectal surgery

1 Facilities for Ambulatory Surgery.- 2 Anesthesia in Ambulatory Anorectal Surgery.- 3 Selection, Preoperative Assessment, and Education of the Patient for Ambulatory Surgery.- 4 Positioning the Patient for Anorectal Surgical Procedures.- 5 Postoperative Management.- 6 Management of Pain After Anorectal Surgery.- 7 Prevention of Urinary Retention After Anorectal Surgery...- 8 Hemorrhoidectomy.- 9 Anal Fissure.- 10 Anorectal Abscess and Fistula-in-Ano.- 11 Management of Rectovaginal Fistulae.- 12 Miscellaneous Surgical Procedures: Treatments for Condyloma Acuminatum, Sacrococcygeal Pilonidal Disease, and Fecal Impaction Examination Under Anesthesia and Minor Revision of Intestinal Stomas.- 13 Rectal Prolapse and Rectocele.- 14 Colonoscopy.- 15 Local Treatment of Rectal Cancer.- 16 Coding and Billing for Colon and Rectal Surgery.- 17 Ambulatory Anorectal Surgery in Australia.

Complex rectovaginal fistulas after pelvic organ prolapse repair with synthetic mesh: a multidisciplinary approach to evaluation and management.

Objectives The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management. Methods Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution. Results Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain. Conclusions This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

Imaging of Colonic Diverticular Disease

Diverticular disease affects approximately two thirds of the population over the age of 70. While only a small fraction of these patients will develop diverticulitis, adequate radiological evaluation of diverticulitis and its complications is imperative in determining proper medical and surgical treatment. Clinical examination and laboratory tests alone have been found to be inaccurate in defining many aspects of the disease in up to 60% of cases. Over the past 30 years, contrast enema, computed tomography, and ultrasound have all been used extensively to diagnose the complications of diverticular disease. More recently, magnetic resonance imaging has been studied in patients with complicated diverticulitis. This article reviews the use of these different radiological modalities in diagnosing acute colonic diverticulitis and its complications.

The argon beam coagulator: A more effective and expeditious way to address presacral bleeding

Presacral bleeding is a dreaded complication of pelvic surgery. Rapid and effective control of such bleeding is important to avoid potentially life-threatening outcomes. Various methods for controlling presacral bleeding, all with only limited success, have been described in the literature. We report the alternative technique of using the argon beam coagulator (ABC) to control presacral bleeding. We demonstrate its efficacious use in both open surgery and a laparoscopic case. Our approach involved applying an argon beam at bone setting directly to the bleeders and using a “point and shoot” technique. We found that ABC is a simpler, equally effective and expeditious way of addressing presacral bleeding. To the best of our knowledge, there has been only one previously reported case in the literature of the use of ABC to control presacral bleeding.

Treatment of Refractory Gastrointestinal Bleeding in Patients With Portal Hypertension: A Case Series and Treatment Algorithm

In patients with portal hypertension, ectopic varices can develop at any site along the gastrointestinal tract outside the classically described gastroesophageal location. Like esophageal variceal hemorrhage, bleeding from ectopic varices can be life-threatening. Diagnosis and treatment of ectopic varices can be challenging; to date, no effective treatment algorithm has been described. A systematic teamwork approach to diagnosing and treatment of ectopic varices is required to successfully manage hemorrhage from ectopic varices.

Die Behandlung des schwierigen, zur Resektion überwiesenen Kolonpolyps: resezieren oder rekoloskopieren?

ZusammenfassungFragestellung und Hintergrund:Patienten werden häufig zur Resektion schwieriger Kolonpolypen überwiesen. Vor einer Kolonresektion hat der erfahrene Chirurg die Wahl, die Koloskopie zu wiederholen, um den Polypen erneut zu beurteilen, die Lokalisation zu markieren und evtl. den Polypen zu entfernen. Ziel dieser Studie war die Untersuchung der eigenen Ergebnisse anhand dieses Ansatzes.Patienten und Methodik:Es wurden alle neuen Patienten retrospektiv untersucht, die mit der Diagnose eines zuvor nicht entfernten Kolonpolypen (CPT 211.3) während eines Zeitraums von 5 Jahren zu einer elfköpfigen Gruppe kolorektaler Chirurgen überwiesen wurden. Patienten mit rektalen Polypen, entzündlicher Darmerkrankung, früheren Karzinomen oder familiärer adenomatöser Polypose wurden ausgeschlossen. Patientendemographie, Details des Polypen, Erfolg der Polypektomie, Gründe für eine chirurgische Resektion, Pathologie und Komplikationen wurden analysiert.Ergebnisse:Die Studienpopulation bestand aus 252 Patienten mit einem mittleren Alter von 65 Jahren. 80 Patienten erhielten nach Einweisung eine Resektion ohne Wiederholungskoloskopie. Bei der Resektion wurden in 13 Fällen invasive Karzinome gefunden. Insgesamt 172 Patienten unterzogen sich mindestens einer Wiederholungskoloskopie durch einen kolorektalen Chirurgen. Bei 101 Patienten dieser Gruppe war die Polypektomie erfolgreich, so dass eine größere Kolonresektion vermieden werden konnte. Die übrigen 71 Patienten unterzogen sich nach mindestens einer Wiederholungskoloskopie einer anschließenden Kolonresektion. In 26 Fällen wurde die Stelle, an der sich der Polyp befand, zur späteren Lokalisierung gekennzeichnet. Neun Blutungen nach einer Polypektomie und zwei Perforationen wurden nichtoperativ behandelt.Schlussfolgerung:Eine wiederholte Koloskopie durch einen erfahrenen Chirurgen führt zu einer kompletten Beseitigung des Karzinoms und zur Vermeidung einer größeren Kolonresektion in 58% dieser Fälle. Bei Patienten, die mit großen schwierigen Polypen zur Resektion überwiesen werden, sollte vor der Operation eine Wiederholungskoloskopie erwogen werden.AbstractPurpose:Patients are frequently referred for resection of difficult colon polyps. Before colectomy the experienced surgeon has the option of repeating the colonoscopy to assess the polyp, tattoo the site, and potentially remove the polyp. The purpose of this study was to review our results with this approach.Methods:All new patients referred during a five-year period to an 11-physician colon and rectal surgical group with the diagnosis of colon polyp (CPT 211.3) that was not previously removed were retrospectively reviewed. Patients with rectal polyps, inflammatory bowel disease, previous cancer, or familial adenomatous polyposis were excluded. Patient demographics, details of the polyps, success of polypectomy, reasons for surgical resection, pathology, and complications were analyzed.Results:The study population consisted of 252 patients with a mean age of 65 years. Eighty patients underwent resection upon referral without a repeat colonoscopy. Upon resection, invasive cancers were found in 13 cases. A total of 172 patients underwent at least one repeat colonoscopy by the colorectal surgeon. Of this group, 101 patients had successful polypectomy, thus avoiding major colectomy. The remaining 71 patients had a subsequent colon resection after at least one repeat colonoscopy. In 26 cases the polyp site was tattooed for later localization. There were nine postpolypectomy hemorrhages treated nonoperatively and two perforations.Conclusion:Repeat colonoscopy by an experienced surgeon leads to complete removal and avoidance of major colectomy in 58 percent of these cases. Patients with large difficult polyps referred for resection should be considered for repeat colonoscopy before surgery.