EFFECTIVENESS OF THE LIGATION OF INTERSPHINCTERIC FISTULA TRACT (LIFT) IN THE TREATMENT OF ANAL FISTULA: INITIAL RESULTS

Background

The abscesses and anal fistulas represent about 70% of perianal suppuration, with an estimated incidence of 1/10000 inhabitants per year and representing 5% of queries in coloproctology.

Aim

To evaluate the effectiveness of the interesphincteric ligation technique of the fistulous tract in the treatment of anal fistula.

Methods

The records of eight patients who underwent this technique, evaluating age, gender and presence of incontinence were studied. Was named technical first-step the passage of cotton thread to promote the correct individualization of the fistula and, as the second, the surgical procedure.

Results

Two patients were men and eight women. The mean age was 42.8 years. Of these, seven (87.5%) had complete healing of the fistula; six were cured only with this procedure and one required additional operation with simple fistulotomy. Only one patient developed fecal incontinence which was documented by anorectal manometry. There were no deaths in this series.

Conclusion

The interesphincteric ligation technique of the fistulous tract proved to be effective for the treatment of anal fistula and should not be discouraged despite the occurrence of eventual fecal incontinence.     

Video-Assisted Anal Fistula Treatment

Background and Objectives:

Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. The latest addition to the list of treatment options is video-assisted anal fistula treatment (VAAFT). It is a minimally invasive, sphincter-saving procedure with low morbidity. The aim of our study was to compare the results with a premier study done previously.

Methods:

The procedure involves diagnostic fistuloscopy and visualization of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with a stapling device or suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source.

Results:

The study was conducted from July 2010 to March 2014. Eighty-two patients with fistula in ano were operated on with VAAFT and were followed up according to the study protocol. The recurrence rate was 15.85%, with recurrences developing in 13 cases. Postoperative pain and discomfort were minimal.

Conclusion:

VAAFT is a minimally invasive procedure performed under direct visualization. It enables visualization of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite encouraging.     

Treatment of complex perianal fistulas in Crohn disease: infliximab,surgery or combined approach

Background

The aim of this study was to compare the outcomes of the management of perianal fistulas in Crohn disease between infliximab, surgery or a combination of surgery and infliximab.

Methods

We prospectively subdivided 35 consecutive patients with Crohn disease with complex perianal fistulas into 3 groups: 11 patients received infliximab (5 mg/kg intravenously at 0, 2 and 6 wk; group A), 10 underwent surgery (group B) and 14 received a combination of surgery and postoperative infliximab (group C). We evaluated the rate and time of healing of perianal fistulas, the rate of recurrences and time to relapse at a median follow-up of 18.8 (standard deviation [SD] 10.8, range 8–38) months.

Results

The time to healing of fistulas was significantly shorter among patients who received surgery and infliximab than among those who received surgery alone (p < 0.05) and was close to statistically shorter among those who received both treatments than among those who received infliximab alone (p = 0.06). Patients who received surgery and infliximab had a significantly longer mean time to relapse (p < 0.05) than those who received infliximab (mean 2.6 [SD 0.7] mo) or surgery alone (mean 3.6 [SD 0.5] mo).

Conclusion

We found better outcomes among patients who received a combination of surgery and infliximab therapy. These patients experienced a short time to healing of fistulas and significantly longer mean time to relapse of complex fistulas.     

VIDEO-ASSISTED ANAL FISTULA TREATMENT: TECHNICAL CONSIDERATIONS AND PRELIMINARY RESULTS OF THE FIRST BRAZILIAN EXPERIENCE

Backgroung

Anorectal fistula represents an epithelized communication path of infectious origin between the rectum or anal canal and the perianal region. The association of endoscopic surgery with the minimally invasive approach led to the development of the video-assisted anal fistula treatment.

Aim

To describe the technique and initial experience with the technique video-assisted for anal fistula treatment.

Technique

A Karl Storz video equipment was used. Main steps included the visualization of the fistula tract using the fistuloscope, the correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening which can be accomplished through firing a stapler, cutaneous-mucosal flap, or direct closure using suture.

Results

The mean distance between the anal verge and the external anal orifice was 5.5 cm. Mean operative time was 31.75 min. In all cases, the internal fistula opening could be identified after complete fistuloscopy. In all cases, internal fistula opening was closed using full-thickness suture. There were no intraoperative or postoperative complications. After a 5-month follow-up, recurrence was observed in one (12.5%) patient.

Conclusion

Video-assisted anal fistula treatment is feasible, reproducible, and safe. It enables direct visualization of the fistula tract, internal opening and secondary paths.     

Successful closure of gastrocutaneous fistulas using the Surgisis? anal fistula plug

Introduction

Gastrocutaneous fistulas remain an uncommon complication of upper gastrointestinal surgery. Less common but equally problematic are gastrocutaneous fistulas secondary to non-healing gastrostomies. Both are associated with considerable morbidity and mortality. Surgical repair remains the gold standard of care. For those unfit for surgical intervention, results from conservative management can be disappointing. We describe a case series of seven patients with gastrocutaneous fistulas who were unfit for surgical intervention. These patients were managed successfully in a minimally invasive manner using the Surgisis^® (Cook Surgical, Bloomington, IN, US) anal fistula plug.

Methods

Between September 2008 and January 2009, seven patients with gastrocutaneous fistulas presented to Wishaw General Hospital. Four gastrocutaneous fistulas represented non-healing gastrostomies, two followed an anastomotic leak after an oesophagectomy and one following an anastomotic leak after a distal gastrectomy. All patients had poor nutritional reserve with no other identifiable reason for failure to heal. All were deemed unfit for surgical intervention. Five gastrocutaneous fistulas were closed successfully using the Surgisis^® anal fistula plug positioned directly into the fistula tract under local anaesthesia and two gastrocutaneous fistulas were closed successfully using the Surgisis^® anal fistula positioned endoscopically using a rendezvous technique.

Results

For the five patients with gastrocutaneous fistulas closed directly under local anaesthesia, oral alimentation was reinstated immediately. Fistula output ceased on day 12 with complete epithelialisation occurring at a median of day 26. For the two gastrocutaneous fistulas closed endoscopically using the rendezvous technique, oral alimentation was reinstated on day 5 with immediate cessation of fistula output. Follow-up upper gastrointestinal endoscopy confirmed re-epithelialisation at eight weeks. In none of the cases has there been fistula recurrence (range of follow-up duration: 30–59 months).

Conclusions

Surgisis^® anal fistula plugs can be used safely and effectively to close gastrocutaneous fistulas in a minimally invasive manner in patients unfit for surgical intervention.     

Robotic-assisted laparoscopic repair of a vesicouterine fistula

Background:

As cesarean sections become a more common mode of delivery, they have become the most likely cause of vesicouterine fistula formation. The associated pathology with repeat cesarean deliveries may make repair of these fistulas difficult. Computer-enhanced telesurgery, also known as robotic-assisted surgery, offers a 3-dimensional view of the operative field and allows for intricate movements necessary for complex suturing and dissection. These qualities are advantageous in vesicouterine fistula repair.

Case:

A healthy 34-year-old woman who underwent 4 cesarean deliveries presented with a persistent vesicouterine fistula. Conservative management with bladder decompression and amenorrhea-inducing agents failed.

Results:

Robotic-assisted laparoscopic repair was successfully performed with the patient maintaining continence after surgery.

Conclusion:

Robotic-assisted laparoscopic repair of vesicouterine fistulas offers a minimally invasive approach to treatment of a complex disease process.     

A late-recognized Currarino syndrome in an adult revealed by an anal fistula

INTRODUCTION

Currarino syndrome (CS) is characterized by the triad of anorectal malformations, sacral bone defects, and presacral mass in which an autosomal dominant inheritance has been described. The surgical community has a little no knowledge of CS in adults, apart from, perhaps, a small number of paediatric surgeons. Therefore, we sought to describe this unusual cause of anal fistula.

PRESENTATION OF CASE

A 55-year-old man was referred with an anal fistula. The patient was scheduled for drainage of multiple collections and an anal fistulectomy. Cytological results were confirmed that the cyst was dermoid (and non abscess). One month after surgery, the patient informs us of his CS. MRI was performed and it revealed an anterior sacral mass. It was to decide to realize an exeresis of this mass by coelioscopy. The patient experienced severely constipated and urinary retention. After therapy by Peristeen anal irrigation and self Intermittent catheterization (six times daily), there was a good improvement in symptoms.

DISCUSSION

This is an extremely rare case of CS revealed in an adult. MRI is a sensitive non-invasive diagnostic tool, and could be performed on any patient with long-standing anal fistula.

CONCLUSION

We recommend an early and multidisciplinary approach of CS is suspected in a patient. The surgeon must always be alert to the possibility of pelvic nerves injury during an exeresis of a retrorectal tumour fistulized.     

Lesion mimicking perianal abscess in an immunocompromised patient: Report of a case

INTRODUCTION

Ischiorrectal tumoral masses mimicking perianal abscess and abscess from uncommon microbiological origins have previously been reported.

PRESENTATION OF CASE

Unusual perianal abscess arising from an hematoma in an elderly woman with myelodysplastic syndrome: the patient presented on the emergency with gluteal pain and fever after intramuscular injection of analgesic drug. Physical examination revealed subcutaneous thickening on gluteus and perianal region, without skin changes. Magnetic resonance reported an heterogeneous mass sized 5 cm × 12 cm × 20 cm from gluteus maximus to ischioanal fat under levator ani muscle, through sciatic notch. Debridement of an staphylococceal infected hematoma through a single left lateral gluteus incision, and primary closure was performed. Proctologic examination was normal, so any perianal incision was done. The site infection progressed, so the patient required new surgery with wet cure. The patient contracted nosocomial pneumonia and died due to sepsis.

DISCUSSION

Hematological diseases can yield infectious and bleeding disorders. Intramuscular injections often cause haematomas that can lead to pyomyositis. Pyomyositis requires early debridement and continue cure.

CONCLUSION

Intramuscular administration of drugs should be avoided in patients with thrombocytopenia. Gluteal region is connected to perianal area through the sciatic notch. Usually perianal abscess in immunocompromised patients arise from proctologic origin, but other causes may be taken into account.     

Distal Revascularisation with Interval Ligation (DRIL): An Experience

INTRODUCTION

The global increase of chronic renal failure has resulted in a growing number of patients on haemodialysis using arteriovenous fistulas (AVFs). By virtue of their very function, AVFs at times shunt blood away from regions distally, resulting in an ischaemic steal syndrome. Distal revascularisation with interval ligation (DRIL) has been described as a procedure to treat symptomatic ischaemic steal. We present our experience in the management of this complication.

PATIENTS AND METHODS

Six patients with severe ischaemic steal were treated using a DRIL procedure between May 2004 and June 2007. There were three males and three females, all with elbow brachiocephalic AVFs. Symptoms ranged from severe rest pain to digital gangrene. Published results from international studies of 135 DRIL procedures were also reviewed.

RESULTS

Vascular access was maintained along with the elimination of ischaemic symptoms in the six patients using an ipsilateral reversed basilic vein graft. Interval ligation of the distal brachial artery was performed at the same time. All patients showed immediate and sustained clinical improvement of symptoms with a demonstrable increase in digital pulse oximetry.

CONCLUSIONS

DRIL is a beneficial treatment option that has proven successful at alleviating ischemic steal symptoms and preserving vascular access. This avoids placement of central lines, its associated risks, and the need to create an alternative sited fistula.     

Salpingo-ureteric fistula—A rare complication following laparoscopic surgery for colorectal cancer: A case report and literature review

INTRODUCTION

We report the management and outcome of the case of a 57-year old woman with adenocarcinoma of the rectum. Following neo-adjuvant chemo-radiotherapy and laparoscopic-assisted anterior resection of her tumour she developed a right salpingo-ureteric fistula.

PRESENTATION OF CASE

Three weeks following laparoscopic anterior resection of the tumour she presented with urinary frequency and incontinence. A ureteric stent was inserted and left in-situ for five months but the fistula did not heal. The patient underwent exploration and open repair of the salpingo-ureteric fistula which resolved her symptoms.

DISCUSSION

There have not been many reported cases in the literature of salpingo-ureteric fistulae but after initial trial of management with ureteric stents all eventually required open exploration and repair.

CONCLUSION

we advocate open repair of salpingo-ureteric fistulae as the definitive management following intra-operative injury.     

Thoracoscopic Thoracic Duct Ligation for Persistent Cervical Chyle Leak: Utility of Immediate Pathologic Confirmation

Objective:

Chylous fistulas can occur after neck surgery. Both nonoperative measures and direct fistula ligation may lead to fistula resolution. However, a refractory fistula requires upstream thoracic duct ligation. This can be accomplished minimally invasively. Success depends on lymphatic flow interruption where the duct enters the thorax. We report on the utility of frozen section confirmation in achieving this goal.

Methods:

Persistent chylous fistulas occurred in 2 patients after left cervical operations. In the first patient, attempted direct fistula ligation and sclerosant application failed. Fasting, parenteral nutrition, and somatostatin-analog provided no benefit. For the second patient, nonoperative treatment was also ineffective. Prior radiation therapy and multiple cervical operations militated against attempted direct fistula ligation. Both patients underwent thoracoscopic thoracic duct interruption.

Results:

In both cases, a duct candidate was identified between the aorta and azygos vein. Frozen section analysis of tissue resected between endoclips verified it as thoracic duct. Fistula resolution ensued promptly in both instances.

Conclusions:

This report lends further credence to the efficacy of minimally invasive thoracic duct ligation in treating postoperative cervical chylous fistulas. Frozen section confirmation of thoracic duct tissue is useful. It allows one facile with thoracoscopy, but less familiar with thoracic duct ligation, to confidently terminate the operation.     

Gallbaldder perforation causing a subcutaneous abscess

INTRODUCTION

This is a report of a rare case of an old woman with a large round mass in the right hypochondrium that was proven to be an abscess.

PRESENTATION OF CASE

A 82-year old woman with a firm round mass in the right hypochondrium was admitted for evaluation. The abdominal CT showed an abscess produced by a gallbladder perforation, and a gallstone impacted at the Hartmann''s pouch.

DISCUSSION

The abscess was treated with a transcutaneous paracentesis, while the stone passed to the gastrointestinal tract through a cholecystoenteric fistula, without causing any further problems.

CONCLUSION

Gallbaldder perforation can rarely create a subcutaneous abscess especially in thin, elder subjects. Abscess drainage is the first line of treatment.     

Perianale Fistel und Analfissur

Cryptoglandular anal fistula

Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points.

Anal fissures

Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation.     

An unusual ischiorectal fossa mass

INTRODUCTION

Peri-anal fistulae commonly present with collections requiring surgical intervention. The most common cause of a peri-anal mass is abscess formation secondary to anal gland sepsis. In certain patient groups such as those over 65 or with atypical presenting symptoms there are other important considerations.

PRESENTATION OF CASE

A 70-year old male was referred by his general practitioner with symptoms of obstructed defaecation and a palpable mass in the ischiorectal fossa. He had previously undergone three operations for complex peri-anal fistulae in another hospital. Due to the previous history of surgery, seroma formation was considered and computed tomography guided drainage of the lesion was performed unsuccessfully. Given symptoms of obstructed defecation and need for histological diagnosis excision was undertaken. The approach was through a right pararectal incision over the bulk of the mass. Skin and pararectal tissue were divided revealing a mucinous lesion with multiple lobules adherent to pararectal tissue. Following histopathological examination a diagnosis of low grade mucinous neoplasm was made.

DISCUSSION

Primary mucinous neoplasm in the ischiorectal fossa is very rare. Diagnostic criteria for adenocarcinoma arising from perianal fistulae have previously been established by Rosser et al. but this lesion does not fall into this category. It is categorised as a mucinous cystic neoplasm of uncertain malignant potential. The differential diagnoses are discussed.

CONCLUSION

Consideration should be given to a range of pathologies in cases of atypical peri-anal masses.     

The Gatekeeper™ for fecal incontinence: Another trial and error

INTRODUCTION

The Gatekeeper™ is the most recent bulking agent used in the treatment of fecal incontinence with no reported complications. This case reports side effects similar to other bulking agents, namely migration of the prosthesis and perianal abscess.

PRESENTATION OF CASE

A 52 year old gentleman presented with a history of fecal soiling. He underwent uncomplicated surgery in 2012 for 6 Gatekeeper™ implantations with only temporary improvements. In 2013, endorectal ultrasound revealed prosthesis migration. In 2014, he presented with a perianal abscess which contained one of the prosthesis.

DISCUSSION

The Gatekeeper™, made of the inert Hyexpan, typically implanted in the intersphincteric region, has been used for the treatment of fecal incontinence since its discontinuation in the treatment of gastroesophageal reflux disease.⁵ The Gatekeeper™ was implemented on a small number of subjects for which the typical side effects of bulking agents were not seen.

CONCLUSION

Larger studies need to be conducted to investigate the advantages or perhaps disadvantages of the Gatekeeper™ over other bulking agents.     

MRI evaluation of not complicated Tailgut cyst: Case report

INTRODUCTION

The Tailgut cyst (cystic hamartoma) is an uncommon congenital disease of presacral retrorectal space and is embryologically part of some forms of enteric cysts. It is a benign malformation, although cases have been described in neoplastic degeneration.

PRESENTATION OF CASE

A caucasian 24 year old female presented shortly after childbirth with hypogastric abdominal discomfort associated with rectal tenderness, bleeding and moderate urinary symptoms for about three weeks. No previous similar episodes were reported. The patient was not suffering from haemorrhoids or inflammatory disease of the gastrointestinal tract.Clinical examination revealed no significant abnormalities or in the perianal area and gluteal surface.Digital rectal examination was suspicious of the presence of a presacral retrorectal mass. However, it could not exclude a trans-sphinteric perianal fistula. There was no fistulous communication with the exterior and the pain seemed to be more pronounced in the rectum.MRI, which has a diagnostic accuracy of 76–100% for the detection of any perianal fistulae, was performed and demonstrated the presence of a retrorectal cystic hamartoma (Tailgut cyst).

DISCUSSION

The most common retrorectal space cystic lesions includes epidermoid cysts, dermoid cysts and enteric cysts. It presents with pelvic pain, and sometimes with local abscess, secondary to a sinus cyst. There can also be a communication between Tailgut cyst and fistula; in the absence of primary infection may develop postinflammatory fibrosis. Radiological investigation is carried out by TRUS, CT and MRI. During MRI, on T1-weighted images, the signal intensity may change from hypointense to hyperintense as protein concentration increases, as well as in the case of bleeding. On T2-weighted images, signal intensity of mucinous fluids can decrease from highly hyperintense to hypointense with increasing protein concentration and viscosity.

CONCLUSION

MRI is a non-invasive useful imaging investigation with high diagnostic accuracy when a retrorectal cyst is suspected. Despite its rarity, Tailgut cyst should be considered, both for acute complications, like infection or bleeding, and for the risk, however infrequent, of neoplastic degeneration.     

Mucinous carcinoma of the anal canal arising from perianal fistula

Background

Anal carcinomas account for 1.5% of all gastrointestinal carcinomas. They may occur in the anal canal, perianal region (up to 5 cm) and surrounding skin. Squamous cell carcinoma (SCC) is the most frequent type (80%), while adenocarcinoma of the anal canal (ACC) accounts for 10% of all anal carcinomas. The remaining 5% includes neuroendocrine neoplasms, mesenchymal tumours, lymphomas, melanocyte tumours and secondary tumours. ACCs arise from chronic fistula or anal glands and they are very rare.

Methods

We report one case of rare adenocarcinoma that originated from perianal fistula. There is not definitive strategy about cure.

Conclusion

Inflammatory perianal tumour often causes late diagnosis or misdiagnosis of ACC, which is due to frequent perianal abscesses at the external perianal fistula opening. The presence of mucin may increase the index of suspicion for malignancy.

     

Colo-vesical fistula: Complete healing without surgical intervention

INTRODUCTION

Colo-vesical (CV) fistulae are the most common type of fistulae associated with diverticular disease. Surgery remains the mainstay of treatment, without which, CV fistulae rarely achieve complete healing.

PRESENTATION OF CASE

Herein, we report the case of a 62-year-old man who developed a CV fistula after reversal of Hartmann''s procedure (initially for management of diverticular abscess), which healed with conservative management alone.

DISCUSSION

We discuss possibilities of the aetiology of this fistula. The CV fistula may have been initially present, which came to light only after his reversal. Or an iatrogenic fistula that developed at the time of reversal of Hartmann''s.

CONCLUSION

This is the first time that such a fistula has been demonstrated clinically and radiologically to have healed spontaneously without surgery. We recommend that conservative management of CV fistulae should be considered.     

Using the StomaphyX(TM) endoplicator to treat a gastric bypass complication

Background and Objectives:

As the number of bariatric operations performed increases, the number of patients requiring reoperation for failed weight loss is expected to proportionately increase. Natural orifice surgery is an alternative approach to revisional gastric bypass surgery when postoperative complications, such as dilatation of the gastrojejunostomy, gastrogastric fistula, and gastric pouch, dilation occur.

Methods:

The present article reports on the safe and successful use of an endoscopic tissue plicating device in a patient found to have a dilated gastric pouch and a gastrogastric fistula 12 years after an open, nondivided RYGB.

Results:

The procedure was performed without complications and resulted in a reduced pouch size to approximately 30cc to 50cc and redirection of the flow of gastric contents through her gastrojejunostomy. The patient''s early satiety returned and, 1 year postoperatively, she had incurred a 45-pound weight loss.

Discussion:

The morbidity and mortality of revision gastric bypass was avoided while the patient''s goal of moderate weight loss was achieved. Tissue plicating devices offer an alternative for repair of some postbariatric complications. With the rapid advances in endoluminal technology and increasing experience with natural orifice surgery, the ability to successfully address surgical problems through less invasive means will continue to improve.     

A case of a bleeding benign gastrocolic fistula in 2014

INTRODUCTION

In the era of proton pump inhibitors in the treatment of peptic ulcer disease, the incidence of a gastrocolic fistula arising from unoperated gastric ulcers is extremely low.

PRESENTATION OF CASE

We present the case of a 68-year old farmer who presented with melaena and was found to have a benign gastrocolic fistula in the setting of untreated peptic ulcer disease, chronic NSAID ingestion and heavy alcohol intake. The diagnosis was made by gastroscopy. En bloc surgery was undertaken due to the size of the fistula and concomitant significant bleeding of the ulcer which would not have made it amenable to medical management.

DISCUSSION

The symptoms of a gastrocolic fistula are undifferentiated and the diagnosis can easily be missed in the setting of other complications such as bleeding or perforation of a hollow viscus. Barium enamas are the most accurate for the diagnosis but gastroscopy with biopsy is usually performed to rule out malignancy. The mainstay of treatment is usually surgical, though patients can be medically managed if he/she is not a surgical candidate.

CONCLUSION

Benign gastrocolic fistulas are rare and its diagnosis is easily missed.