W. Douglas Wong

Anal fistula surgery: Factors associated with recurrence and incontinence

PURPOSE: This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence. METHODS: We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n=300), seton placement (n=63), endorectal advancement flap (n=3), and other (n=9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis. RESULTS: The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery. CONCLUSIONS: Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.

Practice parameters for the treatment of sigmoid diverticulitis - Supporting documentation

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.

Accuracy of Endorectal Ultrasonography in Preoperative Staging of Rectal Tumors

PURPOSE: Preoperative staging of rectal tumors is considered essential to tailor treatment for individual patients. The aim of the present study was to evaluate the accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. METHODS: Eleven hundred eighty-four patients with rectal adenocarcinoma or villous adenoma underwent endorectal ultrasonography evaluation at a single institution during a ten-year period. We compared the endorectal ultrasonography staging with the pathology findings based on the surgical specimens in 545 patients who had surgery (307 by transanal excision, 238 by radical proctectomy) without adjuvant preoperative chemoradiation. Comparisons between groups were performed using chi-squared tests and logistic regression analysis. RESULTS: Overall accuracy in assessing the level of rectal wall invasion was 69 percent, with 18 percent of the tumors overstaged and 13 percent understaged. Accuracy depended on the tumor stage and on the ultrasonographer. Overall accuracy in assessing nodal involvement in the 238 patients treated with radical surgery was 64 percent, with 25 percent overstaged and 11 percent understaged. CONCLUSION: The accuracy of endorectal ultrasonography in assessing the depth of tumor invasion, particularly for early cancers, is lower than previously reported. The technique is more precise in distinguishing between benign tumors and invasive cancers and between tumors localized to the rectal wall and tumors with transmural invasion. Differences in image interpretation may in part explain discrepancies in accuracy between studies.

Open vs. closed sphincterotomy for chronic anal fissure - Long-term results

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1–6) years. RESULTS: Differences in persistence of symptoms (3.4 OISvs.5.3 percent CIS), recurrence of the fissure (10.9vs.11.7 percent CIS), and need for reoperation (3.4 percent OIStvs.4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3vs.236 percent;P0.062), soiling underclothing (26.7vs.16.1 percent;P< 0.001), and accidental bowel movements (11.8vs.3.1 percent;P< 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.

Complete rectal prolapse: evolution of management and results.

Optional treatment for complete rectal prolapse remains controversial. PURPOSE: We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. METHODS: We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64; range, 12–231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). RESULTS: Median age of patients was 64 (11–100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineal rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61vs. 30 percent,P=0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomyvs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8vs. 5 days,P=0.001). Perineal procedures, however, had a higher recurrence rate (16vs. 5 percent,P=0.002). Functional improvement was not significantly different, and most patients were satisfied with treatment and outcome. CONCLUSIONS: We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate.

Openvs. closed sphincterotomy for chronic anal fissure

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1–6) years. RESULTS: Differences in persistence of symptoms (3.4 OISvs.5.3 percent CIS), recurrence of the fissure (10.9vs.11.7 percent CIS), and need for reoperation (3.4 percent OIStvs.4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3vs.236 percent;P0.062), soiling underclothing (26.7vs.16.1 percent;P< 0.001), and accidental bowel movements (11.8vs.3.1 percent;P< 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.

The ileoanal reservoir

One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and ileus, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. There was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 88 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.

Long-term cost of fecal incontinence secondary to obstetric injuries.

INTRODUCTION: Anal incontinence is eight times more frequent in females than in males because of injuries sustained at childbirth. The aim of the present study was to determine the long-term costs associated with anal incontinence related to obstetric injuries. METHODS: Sixty-three patients with anal incontinence caused by obstetric sphincter injuries answered questionnaires regarding previous treatments, symptoms, and use of protective products. Of the patients, 31 were treated surgically, 11 with biofeedback, 6 with a combination of surgery and biofeedback, and 15 conservatively. Treatments and their respective costs were obtained from patient records, patient questionnaires, billing database, and Health Care Financing Administrations 1996 inpatient database. Costs were expressed in 1996 dollars. RESULTS: The mean incontinence score changed from 26 at evaluation to 16 at follow-up (P<0.001). The average cost per patient was

Anal sphincter integrity and function influences outcome in rectovaginal fistula repair

17,166. Evaluation and follow-up charges totaled

Incontinence after lateral internal sphincterotomy: Anatomic and functional evaluation

65,412, and physiologic assessment accounted for 64 percent of these costs. Treatment charges totaled