Wolfgang B. Gaertner

Fistula-associated anal adenocarcinoma in Crohn's disease

Background: Adenocarcinoma arising from perianal fistulae in patients with Crohns disease (CD) is rare. The literature consists mainly of case reports and small series making characterization of this clinical entity difficult. We present 6 patients with CD and fistula‐associated anal adenocarcinoma (FAAA) and a systematic review of published series. Methods: Retrospective charts were reviewed of 6 consecutive patients with FAAA in CD treated from 1992 through 2007. All available variables of our patients and of all available published cases were included for statistical analysis. Results: All patients treated at our institution had severe perianal CD at presentation. The average age at time of diagnosis was 45.5 years. All patients underwent abdominoperineal resection (APR) and 4 received chemoradiation. Four patients died with metastatic disease, 1 is alive with pelvic recurrence at 55 months, and 1 is alive without evidence of disease at 19 months follow‐up. A total of 23 publications including 65 patients (37 female, mean age 53 years) with FAAA were reviewed in our systematic review. The average fistula duration was 14 years. Mean delay of cancer diagnosis was 11 months. APR was performed in 56 patients with an overall 3‐year survival rate of 54%. Thirteen of 15 patients with node‐positive tumors died with recurrent disease following surgery. Conclusions: Adenocarcinoma arising from long‐standing perianal CD fistulae is being increasingly reported. The outcome is poor following operative treatment, especially if perirectal lymph nodes are involved. Periodical cancer surveillance should be performed in all patients with long‐standing perianal CD fistulae. Inflamm Bowel Dis 2010

The evolving role of laparoscopy in colonic diverticular disease: A systematic review

BackgroundA PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.ResultsElective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.ConclusionsElective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.

Percutaneous drainage of colonic diverticular abscess: is colon resection necessary?

BACKGROUND: Recurrent diverticulitis has been reported in up to 30% to 40% of patients who recover from an episode of colonic diverticular abscess, so elective interval resection is traditionally recommended. OBJECTIVE: The aim of this study was to review the outcomes of patients who underwent percutaneous drainage of colonic diverticular abscess without subsequent operative intervention. DESIGN: This was an observational study. SETTINGS: This investigation was conducted at a tertiary care academic medical center and a single-hospital health system. PATIENTS: Patients treated for symptomatic colonic diverticular abscess from 2002 through 2007 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were complications, recurrence, and colectomy-free survival. RESULTS: Two hundred eighteen patients underwent percutaneous drainage of colonic diverticular abscesses. Thirty-two patients (15%) did not undergo subsequent colonic resection. Abscess location was pelvic (n = 9) and paracolic (n = 23), the mean abscess size was 4.2 cm, and the median duration of percutaneous drainage was 20 days. The comorbidities of this group of patients included severe cardiac disease (n = 16), immunodeficiency (n = 7), and severe pulmonary disease (n = 6). Freedom from recurrence at 7.4 years was 0.58 (95% CI 0.42–0.73). All recurrences were managed nonoperatively. Recurrence was significantly associated with an abscess size larger than 5 cm. Colectomy-free survival at 7.4 years was 0.17 (95% CI 0.13–0.21). LIMITATIONS: This study was limited by its retrospective, nonexperimental design and short follow-up. CONCLUSION: In selected patients, observation after percutaneous drainage of colonic diverticular abscess appears to be a safe and low-risk management option.

Fistula-associated anal adenocarcinoma: good results with aggressive therapy.

PurposeTo evaluate the clinical features, pathology, treatment, and outcome of patients with fistula-associated anal adenocarcinoma.MethodsWe identified 14 patients with histologically proven fistula-associated anal adenocarcinoma. We reviewed their medical records and pathology specimens to characterize their presentation, treatment, and clinical outcome.ResultsNine patients presented with a persistent fistula, 3 with a perianal mass, 1 with pain and drainage, and 1 with a recurrent perianal abscess. The average age at time of diagnosis was 59 (range, 37–76) years. Eleven patients had preexisting chronic anal fistulas. Ten had Crohn’s disease, and 1 had previously received pelvic radiation therapy. The diagnosis of cancer was suspected during physical examination in 6 of the 14 patients (43 percent). Twelve patients had extensive local disease at presentation. Primary abdominoperineal resection was performed in 11 patients, 7 following neoadjuvant chemoradiation. Six patients received postoperative chemotherapy, and 2 received postoperative radiation. Four patients died with metastatic disease. The remaining 10 patients are alive without evidence of disease at a mean follow-up of 64.3 (range, 14–149) months.ConclusionsThe diagnosis of fistula-associated anal adenocarcinoma is often unsuspected. Most patients can be cured with aggressive surgical and adjuvant chemoradiotherapy.

Eosinophilic colitis: university of Minnesota experience and literature review.

Eosinophilic colitis is a rare form of primary eosinophilic gastrointestinal disease that is poorly understood. Neonates and young adults are more frequently affected. Clinical presentation is highly variable depending on the depth of inflammatory response (mucosal, transmural, or serosal). The pathophysiology of eosinophilic colitis is unclear but is suspected to be related to a hypersensitivity reaction given its correlation with other atopic disorders and clinical response to corticosteroid therapy. Diagnosis is that of exclusion and differential diagnoses are many because colonic tissue eosinophilia may occur with other colitides (parasitic, drug-induced, inflammatory bowel disease, and various connective tissue disorders). Similar to other eosinophilic gastrointestinal disorders, steroid-based therapy and diet modification achieve very good and durable responses. In this paper, we present our experience with this rare pathology. Five patients (3 pediatric and 2 adults) presented with diarrhea and hematochezia. Mean age at presentation was 26 years. Mean duration of symptoms before pathologic diagnosis was 8 months. Mean eosinophil count per patient was 31 per high-power field. The pediatric patients responded very well to dietary modifications, with no recurrences. The adult patients were treated with steroids and did not respond. Overall mean followup was 22 (range, 2–48) months.

Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease.

Aim  Surgical repair of recto‐vaginal fistula (RVF) in Crohn’s disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion.

Two Experimental Models for Generating Abdominal Adhesions

PURPOSE To develop dependable rat models for generating abdominal adhesions that allow for objective evaluation and quantification. METHODS Two adhesion models were devised and compared with conventional side-wall models involving cecal abrasion and peritoneal excision or abrasion. model T (tissue): removal of a 2.5 by 2.5 cm segment of full-thickness abdominal wall with overlying skin closure, exposing the viscera to subcutaneous tissue; model M (mesh): removal of an identical segment, replacing the defect with a 2.5 by 2.5 cm polypropylene mesh sewn to the cut edges. This exposed the viscera directly to the mesh surface. Seven days after operation, the character and extent of the adhesions were assessed at autopsy. Results were expressed as the percent area of subcutaneous tissue involved (T) or of mesh surface involved (M). For model T the percent involvement of the circumference of the defect edge was also recorded. The extent of omental and intestinal adhesions were evaluated individually. RESULTS The classical side-wall models showed inconsistent patterns of adhesion formation and were difficult to evaluate. Every animal from both models M and T developed extensive adhesions. The mean coverage of mesh surface (M) was 93% and subcutaneous surface (T) 82%. In model T the mean involvement of the defect cut edge was 80% of the circumference. All model T animals had both intestinal and omental adhesions whereas there were no intestinal attachments in model M. Tenacity of adhesions did not differ significantly between animals or models. CONCLUSIONS Adhesion models M and T are consistent, predictable, and dependable. They each yield extensive adhesion coverage to a defined site, which allow for standardized measurement.

Radial Artery Pseudoaneurysm in the Intensive Care Unit

Pseudoaneurysms may occur at the wrist after catheterization of the radial artery but may also occur after arteriovenous shunting for dialysis or after direct trauma to an artery. Radial artery pseudoaneurysms are being increasingly reported because of widespread use of invasive monitoring. We report a case of radial artery pseudoaneurysm at the wrist related to catheterization. The pseudoaneurysm thrombosed after 6 days of external compression. In selected cases, extended external compression is a useful therapeutic option, especially in patients who are medically unfit to undergo general anesthesia or operative treatment.

Bovine Pericardium Buttress Reinforces Colorectal Anastomoses in a Canine Model

PurposeThe consequences of an anastomotic leak or disruption can be devastating, particularly in the colorectal surgery population. The purpose of this study was to evaluate and compare colon anastomoses with or without a collagen matrix buttress derived from bovine pericardium.MethodsA circular stapler was used to create colon-colon anastomoses in a canine model. Twenty animals underwent two anastomoses each: one buttressed with bovine pericardium, and one without any reinforcement. Staple lines were evaluated at Days 0, 3, 7, 14, 42, and 84. Three animals were killed at each time interval, and evaluation included bursting pressure, bursting location, and histology.ResultsColon segments with nonbuttressed anastomoses were more likely to burst at the staple line (63 percent), whereas buttressed anastomoses were more likely to burst at the adjacent intestine (74 percent; P = 0.048). The burst pressure of nonbuttressed staple lines tended to be consistently, although not significantly, higher than the burst pressure of buttressed staple lines (P = 0.651). At histologic analysis, the bovine pericardium buttress demonstrated an ability to allow cellular ingrowth at Day 3 and neovascularization at Day 7. There was no evidence of stenosis or infection.ConclusionsThe use of a collagen matrix buttress in colorectal anastomoses was safe in a canine model. Our study indicates that true burst strength of the majority of buttressed anastomoses was greater than the adjacent intestine.

Clinical Practice Guideline for the Management of Anal Fissures

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen