Fistulotomy or seton in anal fistula: a decisional algorithm

Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4–6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.     

Clinical Role of Modified Seton Procedure and Coring Out for Treatment of Complex Anal Fistulas Associated With Hidradenitis Suppurativa

A variety of techniques have been described to treat complex anal fistulas. When complex anal fistulas are associated with hidradenitis suppurativa, the treatment has to be appropriately tailored for the severity and distribution of the disease so as to remove the external fistula tract to prevent recurrence while ensuring fecal continence. Between 2007 and 2011, a total of 10 males (ranging in age from 32 to 54 years) complained of recurrent purulent discharge in the buttocks and thigh regions. The discharge had started about 12 to 18 months prior, and had increased progressively resulting in complex anal fistulas and hidradenitis suppurativa in the buttocks. They underwent surgical operation according to a modified seton procedure for complex anal fistulas and coring out for hidradenitis suppurativa. They were discharged from the hospital in 4 to 5 days, while the seton dropped spontaneously about 6 to 8 months after surgery. They have been well without any morbidities or recurrence. The present paper demonstrates that cases of complex anal fistulas associated with hidradenitis suppurativa can be successfully treated with a modified seton procedure and coring out of hidradenitis suppurativa.Key words: Anal fistula, Hidradenitis suppurativa, Seton procedureThe aim of surgical treatment of anal fistula is to remove the external fistula to prevent recurrence while ensuring fecal continence. Generally, a “lay-open” fistulotomy or fistulectomy is indicated for simple anal fistulas such as inter-sphincteric or low trans-sphincteric fistulas; but other complex types, including trans-sphincteric or supra-sphincteric fistulas, would require the division of a large portion of the external sphincter, thereby increasing the risk of fecal incontinence. Although many procedures have been described, including seton or innovative methods such as advancement flap, anal plugs, and so on,^1–5 no single surgical approach addresses all types of fistulas, and the results have been controversial . To solve this problem, we have used a modified seton technique that dissects out the external fistula tract while preserving the anal sphincter muscle.^6,7In some patients, hidradenitis suppurativa (HS) is associated with a complex anal fistula. Perianal HS is a chronic and recurrent inflammatory, suppurating, and fistulating disease of apocrine sweat glands in the anal skin and soft tissue. There is currently no known cure nor any consistently effective treatment, although a variety of therapies have been tried to treat HS. In some cases with severe HS, wide surgical excision of the affected skin and skin grafting has been applied. However, when HS is associated with a complex anal fistula, wide excision of the skin and subcutaneous tissue in the buttocks region for HS, as well as complete fistulotomy, usually results in large defects in the musculocutaneous structure with morbidities including incontinence. Therefore, the treatment has to be appropriately tailored for the severity and distribution of the disease to maintain the quality of life of the patient. We report here the clinical utility of a combination of a modified seton procedure for treatment of complex anal fistula and coring out for HS.     

Perianale Crohn-Fisteln

Background

Approximately one third of patients with Crohn’s disease develop perianal fistulas. This study was conducted to determinate outcome predictors in patients treated at a specialized multidisciplinary unit.

Patients and methods

Between May 2005 and May 2008, all patients with perianal Crohn’s fistulas were treated by the same surgeon and a gastroenterologist specialized in managing patients with Crohn’s disease. Deep fistulas were treated by fistulotomy. For high fistulas, a noncutting seton was placed followed by maintenance treatment with azathioprine and/or infliximab. “Optimal outcome” was recorded when (a) there was no need for diverting stoma, (b) complete healing was achieved by fistulotomy, or (c) fistula symptoms were under control, i.e. there was no need for treatment extension during follow-up.

Results

Thirty-four male and 32 female patients underwent 100 surgical interventions. The most frequent types of fistula were high trans-sphincteric (62%) and high intersphincteric (15%). Eleven of the 32 females presented with rectovaginal fistulae. At the study end, complete healing was observed in 12 patients and 32 had good control of fistula symptoms. Seven required proctectomy, fistula symptoms were not under control in 12, and three required diverting stoma. Altogether 44 patients (67%) achieved optimal outcome. The following factors were predictors of nonoptimal outcome by multivariate analysis: presence of Crohn’s colitis (P=0.01), age at the onset of Crohn’s disease <20 years (P=0.02), and types of fistula not suitable for fistulotomy (P=0.05).

Conclusions

The multidisciplinary approach at specialized units will lead to successful outcome in >60% of patients with Crohn’s perianal fistulas. The presence of Crohn’s colitis, young age at disease onset, and presence of high fistulas are indicators of poor prognosis.     

Fistulotomy in the Tertiary Setting can Achieve High Rates of Fistula Cure with an Acceptable Risk of Deterioration in Continence

Introduction

Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen.

Methods

Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005–2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained.

Results

Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P?=?0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery.

Conclusions

We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.     

Long-Term Results of Seton Placement for Fistula-in-ano in Infants

Background

The present study aimed to assess the long-term results of seton placement for fistula-in-ano (FIA) in infants.

Methods

Data of patients aged <1 year who presented to our department with perianal abscess (PA) between January 2006 and February 2010 were retrospectively reviewed. Our standard initial treatment for PA was incision and drainage. Patients with systemic diseases and inflammatory bowel diseases were excluded.

Results

Ninety-five patients were treated for PA and/or FIA during the 5-year period, and follow-up data were available for 90 patients. The mean follow-up duration in these patients was 49.8?±?11.4 months, and mean age at presentation was 3.1?±?2.7 months. Of the 90 patients, 36 (40 %) developed FIA (39 lesions) and underwent seton placement. The condition healed in a mean period of 6.3?±?4.0 weeks after the placement of a cutting seton. Healing of the fistula was achieved in 35 (97.2 %) of 36 patients after the initial seton procedure, and one patient who showed recurrence underwent a second seton placement, resulting in successful healing of the FIA after 5 weeks.

Conclusions

The long-term success of seton placement indicates that this procedure should be a treatment option for FIA in infants.     

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction

High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion.

Methods

This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.

Results

Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001).

Conclusions

Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.     

Outcomes of anal fistula surgery in patients with inflammatory bowel disease

Background

Anal fistulas in patients with Crohn's disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion.

Methods

This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively.

Results

Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Paul's Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures.

Conclusions

Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.     

CT virtual cystourethroscopy for complex urethral strictures: an investigative,descriptive study

Purpose

To compare the values of CT virtual cystourethroscopy and of conventional cystourethroscopy in diagnosing complex urethral strictures.

Methods

From January 2012 to December 2012, 33 patients, suspected of having complex urethral strictures before operation, were enrolled in this study. After CT scanning, a virtual cystourethroscopic view was software-generated. Conventional cystourethroscopy was also used before operation. The time durations of virtual cystourethroscopy and conventional cystourethroscopy were recorded. The accuracies of both techniques were compared using the actual findings from the operation.

Results

For 16 patients suffering from urethral strictures associated with various fistulas, the duration of examination with virtual cystourethroscopy was statistically significantly shorter than with conventional cystourethroscopy (P < 0.001). The detection rate of fistula by virtual cystourethroscopy was similar to than by conventional cystourethroscopy (P = 0.057). The same results were obtained in eight patients suffering from urethral strictures associated with false passages. Only virtual cystourethroscopy could reveal the details of the urethral lumen in nine patients suffering from long anterior urethral strictures caused by lichen sclerosus. By contrast, conventional cystourethroscopy failed in those same patients.

Conclusion

CT virtual cystourethroscopy is a useful technique for the diagnosis of urethral disease, especially in male patients suffering from complex urethral strictures.     

York Mason Procedure to Repair Iatrogenic Rectourinary Fistula: Our Experience

Background

Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier’s gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes.

Methods

We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula’s etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up.

Results

In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula’s etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula.

Conclusions

The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.     

Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries

Introduction and hypothesis

Genitourinary fistula poses a public health challenge in areas where women have inadequate access to quality emergency obstetric care. Fistulas typically develop during prolonged, obstructed labor, but providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery.

Methods

This retrospective study analyzes 805 iatrogenic fistulas from a series of 5,959 women undergoing genitourinary fistula repair in 11 countries between 1994 and 2012. Injuries fall into three categories: ureteric, vault, and vesico-[utero]/-cervico-vaginal. This analysis considers the frequency and characteristics of each type of fistula and the risk factors associated with iatrogenic fistula development.

Results

In this large series, 13.2 % of genitourinary fistula repairs were for injuries caused by provider error. A range of cadres conducted procedures resulting in iatrogenic fistula. Four out of five iatrogenic fistulas developed following surgery for obstetric complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus. Others developed during gynecological procedures, most commonly hysterectomy. Vesico-[utero]/-cervico-vaginal fistulas were the most common (43.6 %), followed by ureteric injuries (33.9 %) and vault fistulas (22.5 %). One quarter of women with iatrogenic fistulas had previously undergone a laparotomy, nearly always a cesarean section. Among these women, one quarter had undergone more than one previous cesarean section.

Conclusions

Women with previous cesarean sections are at an increased risk of iatrogenic injury. Work environments must be adequate to reduce surgical error. Training must emphasize the importance of optimal surgical techniques, obstetric decision-making, and alternative ways to deliver dead babies. Iatrogenic fistulas should be recognized as a distinct genitourinary fistula category.     

The Use of the Loose Seton Technique as a Definitive Treatment for Recurrent and Persistent High Trans-Sphincteric Anal Fistulas: A Long-Term Outcome

Background  The loose seton technique (suggested to avoid any external anal division following seton placement, to ensure anal continence) was assessed as the ultimate approach for primary as well as recurrent and persistent anal fistula. Study Design  Between 2000 and 2006, 97 patients were operated for trans-sphincteric anal fistula, 41 patients of whom (42.3%) underwent the loose seton technique. The outcome was assessed periodically at the outpatient colorectal clinic and finally by detailed telephonic questionnaire. Mean age was 45.3 years. Thirty one operations were elective (75.6%). Fifteen (36.5%) patients had concomitant diseases, of whom three suffered from Crohn’s disease. Twenty nine patients had previous anal operations. Results  The time from seton placement to its removal ranged from 3 to 7 months. At short-term follow-up, early complications were noted in five patients (bleeding in one and abscess formation in four). Late complications included liquid stool soiling in one patient (2.4%), solid soiling in two, and mucous discharge in three. Post-operative clinical assessment of incontinence according to Cleveland Clinic Incontinence Score revealed scoring ranging from 2 to 6 in those six patients. Neither gross stool nor flatus incontinence was noted. Fistula recurrence (persistence) was noted in eight (19.5%) patients and successfully treated by the same loose seton technique. Conclusions  The loose seton technique for trans-sphincteric anal fistula carries favorable results and can be safely applied while preserving the external sphincter function. We also recommend repeating the technique in case of post-operative fistula recurrence or persistence.     

Ureterovaginal fistula: a case series

Introduction and hypothesis

We describe the presentation, diagnosis, and management of ureterovaginal fistula over a 7-year period at a tertiary care center.

Methods

A retrospective review of ureterovaginal fistula cases between 2003 and 2011 was performed. Demographic information, antecedent event, symptoms, diagnostic modalities, and management strategies were reviewed.

Results

Nineteen ureterovaginal fistulas were identified during the 7-year study period. One fistula followed a repeat cesarean section and 18 fistulas followed a hysterectomy (9 total abdominal, 6 total laparoscopic, 3 vaginal hysterectomies). Ureteral injuries were not recognized in any of the patients at the time of index surgery. Computed tomography (CT) urography was the most commonly utilized diagnostic modality (58 %). Primary non-surgical management with ureteral stents was attempted and successful in 5 out of 7 cases (71 %). There were 14 total surgical repairs, including 2 cases in which stents were successfully placed, but the fistula persisted, and 6 additional cases where attempted stent placement failed. Surgical repair consisted of 10 ureteroneocystostomies performed via laparotomy and 4 performed laparoscopically, 3 of which were robotically assisted.

Conclusions

Despite being uncommon, ureterovaginal fistula should remain in the differential diagnosis of new post-operative urinary incontinence after gynecological surgery. Conservative management with ureteral stent appears to be the best initial approach in selected patients, with a success rate of 71 %. Minimally invasive approaches to performing ureteroneocystostomy have high success rates, comparable to those of open surgical repair.     

Natural History of Intra-abdominal Fluid Collections Following Pancreatic Surgery

Background

Little data are available for non-abscess abdominal fluid collections (AFCs) after pancreatic surgery and their clinical implications. We sought to analyze the natural history of such collections in a population of patients subject to routine postoperative imaging.

Methods

From 1995 to 2011, 709 patients underwent pancreatic resections and routine postoperative monitoring with abdominal ultrasound according to a unit protocol. AFCs were classified as asymptomatic (no interventional treatment), symptomatic (need for percutaneous drainage of sterile, amylase-poor fluid), and pancreatic fistula (drainage of amylase-rich fluid).

Results

Ninety-seven of 149 AFCs (65 %) were asymptomatic and resolved spontaneously after a median follow-up of 22 days (interquartile range, 9–52 days). Among 52 (35 %) AFCs requiring percutaneous drainage, there were 20 pancreatic fistulas and 32 symptomatic collections. A stepwise logistic regression model identified three factors associated with the need for interventional treatment, i.e., body mass index ≥25 (odds ratio, 3.23; 95 % confidence interval (CI), 1.32 to 7.91), pancreatic fistula (odds ratio, 2.93; 95 % CI, 1.20 to 7.17), and biliary fistula (odds ratio, 3.92; 95 % CI, 1.35 to 11.31).

Conclusions

One fourth of patients develop various types of non-abscess AFCs after pancreatic surgery. Around half of them are asymptomatic and resolve spontaneously.     

Is the enteral replacement of externally drained pancreatic juice valuable after pancreatoduodenectomy?

Purposes

External drainage of pancreatic juice using a pancreatic duct stent following pancreatoduodenectomy is widely performed. We hypothesized that the replacement of externally drained pancreatic juice would help to prevent postoperative complications, including pancreatic fistulas.

Methods

Sixty-four patients who underwent pancreatoduodenectomy between 2006 and 2008 were randomly assigned to either a pancreatic juice non-replacement (NR) or replacement (R) group. Eighteen patients were excluded from the analysis because they had unresectable tumors (n = 4), low pancreatic juice output (<100 ml) (n = 11) or for other reasons (n = 3). A total of 46 patients (NR = 24, R = 22) were included in the final analysis. The volume and amylase levels of externally drained pancreatic juice were analyzed on postoperative days 7 and 14. The incidence of postoperative complications, including pancreatic fistulas and delayed gastric emptying, was also assessed.

Results

The total amylase secretion from the pancreatic tube on postoperative day 7 was significantly higher in the NR group compared with the R group (P = 0.044). The incidence of pancreatic fistulas (>Grade B) was also significantly higher in the NR group (33.3 vs. 9.1 %, P = 0.046).

Conclusions

In cases for whom external pancreatic juice drainage from a stent is applied following pancreaticojejunostomy, enteral replacement of externally drained pancreatic juice may reduce the incidence of postoperative pancreatic fistula formation.     

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 3-year prospective follow-up study

Introduction and hypothesis

To evaluate clinical outcomes at 3 years following total transvaginal mesh (TVM) technique to treat vaginal prolapse.

Methods

Prospective, observational study in patients with prolapse ≥stage II. Success was defined as POP-Q-stage 0-I and absence of surgical re-intervention for prolapse. Secondary outcome measures were: quality of life (QOL), prolapse-specific inventory (PSI), impact on sexual activity and complications.

Results

Ninety women underwent TVM repair, 72 a hysterectomy. Anatomical failure rate was 20.0% at 3 years. Three patients required re-intervention for prolapse. Improvements in QOL- and PSI-scores were observed at 1 and 3 years. Vaginal mesh extrusion occurred in 14.4% patients. After 3 years, 4.7% asymptomatic extrusions remained present. Of 61 sexually active women at baseline, a significant number of patients (41%) ceased sexual activity by 3 years; de novo dyspareunia was reported by 8.8%. One vesico-vaginal fistula resolved after surgery.

Conclusion

Medium-term results demonstrate that the TVM technique provides a durable prolapse repair.     

Aetiology,evaluation and management of rectovaginal fistula: A rare entity and a major surgical challenge

Background

Rectovaginal fistulas occur as a complication of surgery or radiation therapy, an obstetrical trauma, malignant process and inflammatory bowel disease. These fistulas comprise 5% of all anorectal fistulas. The presenting symptoms vary according to the characteristics of the fistula and the underlying cause.

Methods

This review article evaluates in detail each of those aspects from a clinician’s perspective.

Results

Symptoms referring to the aetiology and process of evaluating the location, length and diameter of the fistula are described here in detail as critical to selecting the appropriate surgical technique. However, successful fistula healing is much less than certain after every repair attempt, even in the most experienced hands. Nevertheless, re-operation is deployed in such cases. A diverting colostomy might also be needed as a last resort to relieve the symptoms. Morbidity of a rectovaginal fistula is increased, and from a psychosocial perspective, it can dramatically alter the sexual and reproductive life of a female with consequences to her self-esteem.

Conclusions

The surgical repair of rectovaginal fistulas is a challenge even for the most experienced and dedicated of anal surgeons. Healing rectovaginal fistulas with underlying aetiology might be an unattainable goal even with recurrent attempts, sometimes necessitating amputation surgery.     

Interposition grafts for rectovaginal fistula repair in the New Zealand white rabbit

Introduction and hypothesis

The objective was to use an animal model to study different types of interposition grafts for rectovaginal fistula repair.

Methods

Twelve New Zealand white rabbits underwent surgical creation of a rectovaginal fistula, followed by repair. Four repair techniques were studied; three with interposition grafts and one control group without a graft. Animals were euthanized at 4-week intervals and underwent gross and histologic analysis.

Results

The mean rectovaginal wall thickness was greatest in the control group (5.6 mm) and thinnest in the autologous rectus fascia (4.2 mm) and porcine small intestine submucosa (5.1 mm) groups. The polypropylene graft had a mean thickness of 5.4 mm and elicited a strong, protracted inflammatory response. All fistulas were successfully closed except one porcine small intestine submucosa repair.

Conclusions

There is no benefit from interposition graft use for rectovaginal fistula repair in our New Zealand white rabbit model.     

External Tube Pancreatostomy Reduces the Risk of Mortality Associated with Completion Pancreatectomy for Symptomatic Fistulas Complicating Pancreaticoduodenectomy

Objective

This study aimed to compare the outcome of a pancreas-preserving technique consisting in a two-step procedure (external tube pancreatostomy (ETP) after resection of dehisced anastomosis followed by late anastomosis completion) with that of completion pancreatectomy (CP) for grade C fistulas complicating pancreaticoduodenectomies (PDs).

Background data

CP is the most commonly performed operation to treat a dehisced pancreato-jejunal anastomosis associated with deteriorating clinical status or hemorrhage. However, mortality of CP is high and long-term consequences are severe.

Methods

All consecutive patients who underwent PD between 1990 and 2010 were identified. Clinicopathological data, operative details, and outcomes were analyzed.

Results

Out of 370 patients, 112 (30.2 %) developed a pancreatic fistula, which was severe (grade C) in 47 cases. Forty-two patients were treated surgically by CP (n?=?23; median time following PD, 10 days), ETP (n?=?9; median time following PD, 8 days) or other various procedures (n?=?10). Indications for re-operation and operative time of CP and ETP (207.5′ versus 170′, respectively) were similar, while postoperative mortality was significantly higher after CP (43.5 % versus 0 %, p?=?0.030). Moreover, the need for a second emergency re-operation was threefold higher after CP than after ETP (39.1 % versus 11.1 %). After a median of 88 days, seven patients completed the pancreato-jejunal anastomosis without major complications or mortality. After a median follow-up of 14 months, none of the ETP patients developed diabetes.

Conclusions

External tube pancreatostomy significantly reduces the mortality associated with emergency CP. Thus, it should always be considered when deciding the treatment option in emergency surgery for severe pancreatic fistulas.     

Laparoscopic TME with APPEAR (Anterior and Perineal PlanE for ultra-low Anterior Resection of the Rectum) technique for distal rectal cancer

Background

Laparoscopic sphincter saving rectal resection for low rectal cancer is hampered by narrow pelvis and limitations of current stapling devices [1]. The APPEAR (Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum) was proposed by Williams et al. [2, 3] as an alternative to the abdominal-perineal resection to perform very low rectal resection and anastomosis through a perineal wound. We adapted the original technique to the laparoscopic approach, avoiding any other abdominal incision.

Methods

Between December 2011 and April 2012, five patients (2 females; median age 72 years (range 60–78)) with rectal cancer not involving the sphincters underwent laparoscopic total mesorectal excision (TME) with APPEAR. Mean distance of the tumor from anal verge was 3.2 ± 1.1 cm (range 2–5).

Results

All of the procedures were completed laparoscopically. All of the anastomoses were stapled, and a protective stoma was always constructed. The surgical specimens were retrieved from the perineal wound, and the stoma performed through one of the port sites, without any further abdominal incision. Mean operative time was 333 ± 47 min (range 295–405), postoperative stay 12 ± 5 days (range 6–17). Perineal wound infection was observed in three patients, two of whom also had anastomotic fistula, and was treated conservatively with prolonged suction drainage. Histological examination showed three pT3N+, one T2N0, and one complete response after neoadjuvant radiochemotherapy, with a mean distal clear margin of 1.27 ± 0.5 cm (range 0.5–1.7). After a median follow-up of 9 months (range 8–12), one stoma reversal has been performed and the patient is fully continent.

Conclusions

Our experience shows the feasibility of the APPEAR technique with laparoscopic TME, without any other abdominal incision. This technique offers advantage over the limitations of current laparoscopic stapling devices and their scanty maneuverability in the pelvis, allowing resection and anastomosis under direct vision, with adequate distal clearance, while sparing the anal sphincters.     

A Cost Analysis of Somatostatin use in the Prevention of Pancreatic Fistula after Pancreatectomy

Background

Studies have shown that somatostatin reduces the occurrence of postoperative pancreatic fistula. However, no study to date has analyzed the cost effectiveness of this treatment. The purpose of this study was to analyze the cost effectiveness of prophylactic somatostatin use with respect to pancreatectomy.

Methods

Review of prospectively collected 2002 patient hepato-pancreatico-biliary database from January 2007 to May 2012. Patients received somatostatin prophylactically at the discretion of their surgeon. Data were analyzed using univariate analysis to determine if somatostatin had an effect on imaging costs, lab costs, “other” costs, PT/OT costs, surgery costs, room and board costs, and total hospital costs.

Results

A total of 179 patients underwent pancreatectomy at a single teaching institution. Median total hospital costs were 90,673.50 (59,979–743,667) for patients who developed a postoperative pancreatic fistula versus 86,563 (39,190–463,601) for those who did not (p = 0.004). Median total hospital costs were 89,369 (39,190–743,667) for patients who were administered somatostatin versus 85,291 (40,092–463,601) for patients who did not (p = 0.821).

Conclusions

Pancreatic fistulas significantly increase hospital costs, and somatostatin has been shown to decrease the rate of pancreatic fistula formation. Somatostatin has no significant effect on hospital costs.