William C. Cirocco

Challenging the predictive accuracy of goodsall's rule for anal fistulas

To examine the predictive accuracy of Goodsalls rule, the records of 216 patients (155 men and 61 women) who underwent surgery for complete submuscular anal fistulas from 1982 to 1989 were retrospectively reviewed. In accordance with Goodsalls rule, 90 percent of 124 patients with an external opening posterior to the transverse anal line had anal fistulas tracking to the midline (87 percent men arid 97 percent women). Only 49 percent of the 92 patients with an external opening anterior to the transverse anal line had anal fistulas that tracked in the radial fashion predicted by Goodsall (57 percent men and 31 percent women). Instead, 71 percent of these patients (62 percent men and 90 percent women) had anterior fistulas tracking to the midline. Overall, 81 percent (77 percent men and 93 percent women) of patients had complete submuscular anal fistulas that coursed to the midline (51 percent midline posterior and 30 percent midline anterior). In summary, Goodsalls rule is accurate only when applied to complete submuscular anal fistulas with posterior external anal openings. The rule is inaccurate in describing the course of complete submuscular anal fistulas with an anterior external opening. The men in this group had anal fistulas that defied Goodsalls rule in an unpredictable manner, whereas 90 percent of the women had fistulas tracking to a midline anterior origin.

Life-threatening hemorrhage and exsanguination from Crohn's disease

PURPOSE AND METHODS: From 1979 through 1991, four patients of 631 admissions (0.6 percent) for Crohns disease in Erie, Pennsylvania, presented with life-threatening gastrointestinal hemorrhage. These and 34 similar cases from the medical literature were reviewed to provide a composite of those at risk and elucidate appropriate diagnostic and therapeutic maneuvers. RESULTS: The study revealed a preponderance of young men (2∶1 ratio) with an average age of 35 (range, 14–89) years, the majority of whom had known Crohns disease (60 percent) for an average of 4.6 (range, 0–18) years. The site of bleeding resembled the general distribution for Crohns disease, with small bowel disease predominating (66 percent involved the ileum). The five cases of exsanguination (13 percent of the total) were all men with known Crohns disease (average, 58 years) involving the ileum alone or in part. Mesenteric arteriography was positive in 17 patients, providing precise preoperative localization resulting in no mortality in this group. Excluding those who presented with exsanguination, surgery was necessary to cease hemorrhage in 91 percent (30/33) of patients. Ileocolectomy was the most frequently performed procedure (53 percent). In follow-up, only one patient required further surgical resection for recurrent bleeding (3.5 percent), and two other patients (7 percent) required further therapy for nonhemorrhagic recurrence. CONCLUSION: Crohns disease may be responsible for life-threatening gastrointestinal hemorrhage and even exsanguination. Many of the characteristics of these patients resemble the general Crohns disease population. Surgical resection provides excellent palliation. A long-term benign course can be expected in this subgroup of Crohns disease patients.

The Altemeier procedure for rectal prolapse: an operation for all ages.

PURPOSE: Perineal rectosigmoidectomy was the most popular operation performed for rectal prolapse in the first half of the 20th century. However, high recurrence rates relegated it to a back-up role for elderly or other high-risk patients who were not candidates for an abdominal operation. Recent series (combined with levatorplasty = Altemeier procedure) revealed excellent results across a broader spectrum of patients and inspired this ongoing consecutive series of cases. METHODS: This is a review of 103 (99 women) consecutive patients (mean age, 68.9 y; range, 20–97 y) who underwent the Altemeier procedure between 2000 and 2009. Patients were placed in the prone jackknife position: 93 patients (90%) with the use of general anesthesia and 10 patients (10%) with the use of spinal anesthesia. The mean follow-up was 43 months (range, 3 mo to 10 y). RESULTS: The mean time for the operation was 97.7 minutes (range, 50–180 min) with a mean 7.2 cm of rectum resected (range, 2.5–26.7 cm). The mean blood loss was 66.9 mL (range, 0–350 mL). The mean time to tolerating a diet was 2.3 days (100% within 4 d) and mean postoperative length of hospital stay was 4.2 days (93% within 6 d). There was no mortality, minimal morbidity (14%), and no recurrence. Preoperative constipation (61% of patients) improved in 94% and preoperative fecal incontinence (47% of patients) improved in 85%, whereas 15% developed new onset of seepage or incontinence to flatus. CONCLUSIONS: The Altemeier procedure for rectal prolapse provided excellent results across all age groups with minimal morbidity, allowing for short hospital stays and periods of convalescence. To this point, there has been no evidence of recurrence in this group of patients, pending longer periods of follow-up, especially among patients from the younger age groups.

Confirmation of cecal intubation during colonoscopy

PURPOSE: Establishing intubation of the cecum can be a laborious, frustrating, and sometimes erroneous endeavor. Following confirmed colonoscopic intubation of the cecum, the presence of three anatomic landmarks (alone and in combination) were evaluated to precisely define their reliability. METHODS: Between February 1991 and January 1992, 771 of 904 consecutive colonoscopic examinations were completed to the cecum as confirmed by fluoroscopy. RESULTS: All three cecal landmarks studied (ileocecal valve, appendiceal orifice, and transillumination) were present in 64 percent of patients, and two landmarks were seen in 32 percent (96 percent of patients had multiple landmarks). The ileocecal valve was the most reliable cecal landmark (98 percent), followed by the appendiceal orifice (87 percent) and transillumination through the abdominal wall (75 percent). CONCLUSIONS: The ileocecal valve is the most reliable cecal landmark and is invariably visualized, even when all other cecal landmarks are obscure. Although other cecal landmarks are usually identifiable, they are most valuable when found in association with the ileocecal valve.

Simplified seton management for complex anal fistulas: A novel use for the rubber band ligator

The seton has been useful in the treatment of complex anal fistulas. Various complicated methods to enhance the advancement of the seton through the external sphincter muscles have been described. We use a common office implement, the rubber band ligator, to manage the seton in an outpatient setting.

Documenting the use of fluoroscopy during colonoscopic examination: a prospective study.

SummaryTo determine the patterns of fluoroscopy use during colonoscopy, 500 consecutive patients undergoing colonoscopic examination were studied over a 6-month period. The procedures were performed on 195 patients by three gastroenterologists and on 305 patients by three colon and rectal surgeons. The study group comprised 237 women and 263 men aged an average of 62 years (range, 12–90 years). The results revealed that fluoroscopy was used during 37% of colonoscopic examinations. The most common indications for fluoroscopy were the treatment of sigmoid loops (42%) and the localization of the colonoscope tip (51%), totaling 93% of 312 fluoroscopic checks. The suspected position of the colonoscope tip was inaccurate in 15% (47/312) of fluoroscopic checks. The most common bowel location of the colonoscope tip during the fluoroscopic checks was the hepatic flexure (24%), followed by the cecum (21%). In all, 53% (166/312) of fluoroscopic checks involved the right colon. The selective use of fluoroscopy during more difficult cases was emphasized by the significantly longer time required for the procedure (36 vs 26 min) and the significantly lower cecal intubation rate (79% vs 99%). In summary, fluoroscopy is deemed to be a safe, reliable technique that facilitates the completion of difficult colonoscopic examinations. It is especially helpful in the treatment of sigmoid loops and in the precise localization of the position of the colonoscope tip, especially during negotiation of the right colon.

The Fatal Flaw of Outcome Studies Comparing Colorectal Operations With and Without Mechanical Bowel Preparation: The Absence of Oral Antibiotics!

To the Editor–there have been 2 Current status articles published within a 6-month period in Diseases of the Colon & Rectum regarding the merits of mechanical bowel preparation (mBP) with opposing conclusions. the first carefully selected 36 publications that compared postoperative complications of operations performed with oral mBP versus no oral mBP. only 3 of these studies defined oral MBP as a combination of oral antibiotics and mBP. their nonconclusion was that they “could not exclude modest beneficial or harmful effects of oral mechanical bowel preparation compared with no preparation.” Chen et al reviewed 7 randomized controlled studies of patients receiving a combination of oral and systemic antibiotics combined with mBP versus patients who received systemic antibiotics and mBP alone. the group receiving both oral and systemic antibiotics with mBP had a significantly lower rate of surgical site infection. this is only 1 of many recent publications confirming that mBP alone is not sufficient to decrease surgical site infection; oral antibiotics are required and may also result in decreased rates of anastomotic leak. of course, the importance of combining oral antibiotics with mBP has been documented for decades but discarded, ignored, or never even considered by surgeons influenced by flawed, new-age noninferiority data comparing mBP without oral antibiotics versus no mBP. for instance, the words oral antibiotics cannot be found in the Cochrane contribution to this discussion. the evidence that mBP alone does not lower surgical site infection goes back to 1940, before the discovery and introduction of oral antibiotics. the clearance of solid stool and fecal debris has no impact on bacterial colony counts. unfortunately, this lesson had to be relearned in the 21st century, as thoroughly detailed by fry. the 2 recent Current status contributions with conflicting conclusions, published in Diseases of the Colon & Rectum only months apart, represent the continued confusion regarding this issue. the history and back story to the nichols and Condon publication of the 1970s adding oral antibiotics to mBP confirms that this breakthrough was not so much a revelation as a culmination of decades of study. it has been a fascinating journey, an odyssey that colorectal surgeons should fully appreciate to avoid a future backslide into the misuse of proven, effective methods of patient preparation for elective colorectal operation that should not have to be rediscovered with each succeeding generation of surgeons. nichols and colleagues ask, “have we had the answer all along?” Yes!