Pelvic Necrosis with Formation of a Pelvic "Cloaca" and Necrotizing Soft Tissue Infection After Radiation for Anal Squamous Cell Carcinoma.

BACKGROUND Anal squamous cell carcinoma (SCC) is a rare cancer commonly treated with the Nigro protocol, which combines chemotherapy and radiation. Patients who received radiation therapy prior to modern advances, such as computer-based tumor targeting, volumetric planning, and intensity-modulated radiation therapy, experience more acute and chronic adverse effects. Though exceedingly rare, radiation necrosis is of particular concern, as it can result in significant morbidity and mortality, including complex pelvic fistula formation and predisposition to potentially life-threatening necrotizing soft-tissue infections. CASE REPORT Here, we present a case of a 66-year-old woman with a prior history of anal SCC stage T3N×M0 who was treated with the Nigro protocol. Her treatment course was complicated by radiation proctitis, necessitating fecal diversion and ureteral strictures, requiring frequent stent exchanges. She presented 18 years after her cancer treatment, with widespread necrosis of her pelvic organs and surrounding soft tissue, resulting in formation of a large pelvic "cloaca", with a superimposed necrotizing soft-tissue infection. She was successfully treated by expedited resuscitation, septic source control, using multiple extensive debridements, and complete urinary diversion, utilizing a multidisciplinary team. CONCLUSIONS This case highlights the importance of monitoring patients for signs of radiation toxicity, particularly in patients who received radiation prior to the latest technological advancements, as they are at increased risk of developing severe, late adverse effects decades after treatment. When these complications are recognized, early and aggressive intervention is required to spare the patient significant morbidity and mortality.

Recurrent colon cancer in a patient with Muir-Torre syndrome: a case report.

Muir-Torre syndrome (MTS) is a rare subtype of hereditary nonpolyposis colorectal cancer syndrome caused by a defect in DNA mismatch repair leading to microsatellite instability. It is characterized by the presence of at least one sebaceous gland tumor and one internal malignancy, most commonly colorectal and endometrial tumors. These patients have a high propensity for tumorigenesis, and while strict screening protocols are in place, there are only two cases that describe the management approach to recurrent colon cancer. Here, we present a case of recurrent colorectal cancer in a patient with MTS, and describe how it was managed at our facility by a multidisciplinary team.

Socioeconomic Disparities in Anal Cancer: Effect on Treatment Delay and Survival.

BACKGROUND: Socioeconomic inequities have implications for access to health care and may be associated with disparities in treatment and survival. OBJECTIVE: To investigate the impact of socioeconomic inequities on time to treatment and survival of anal squamous-cell carcinoma. DESIGN: This is a retrospective study using a nationwide data set. SETTINGS: The patients were selected from the National Cancer Database and enrolled from 2004 to 2016. PATIENTS: We identified patients with stage I to III squamous-cell carcinoma of the anus who were treated with chemoradiation therapy. MAIN OUTCOMES MEASURES: Socioeconomic factors, including race, insurance status, median household income, and percentage of the population with no high school degrees, were included. The association of these factors with treatment delay and overall survival was investigated. RESULTS: A total of 24,143 patients who underwent treatment for grade I to III squamous-cell carcinoma of the anus were identified. The median age was 60 years, and 70% of patients were women. The median time to initiation of treatment was 33 days. Patients from zip codes with lower median income, patients with a higher percentage of no high school degree, and patients with other government insurance followed by Medicaid insurance had treatment initiated after 60 days from diagnosis. Kaplan-Meier survival analysis showed that the late-treatment group had worse overall survival compared to the early treatment group (98 vs 125 months; p < 0.001). LIMITATIONS: No detailed information is available about the chemoradiotherapy regimen, completion of treatment, recurrence, disease-free survival, and individual-level socioeconomic condition and risk factors. CONCLUSION: Patients from communities with lower median income, level of education, and enrolled in public insurance had longer time to treatment. Lower socioeconomic status was also associated with poorer overall survival. These results warrant further analysis and measures to improve access to care to address this disparity. See Video Abstract . DESIGUALDADES SOCIOECONMICAS EN CASOS DE CNCER ANAL EFECTOS EN EL RETRASO DEL TRATAMIENTO Y LA SOBREVIDA: ANTECEDENTES:Las desigualdades socio-económicas tienen implicaciones en el acceso a la atención médica y pueden estar asociadas con disparidades en el tratamiento y la sobrevida.OBJETIVO:Indagar el impacto de las desigualdades socio-económicas sobre el tiempo de retraso en el tratamiento y la sobrevida en casos de carcinoma a células escamosas del ano (CCEA).DISEÑO:Estudio retrospectivo utilizando un conjunto de datos a nivel nacional.AJUSTES:Todos aquellos pacientes inscritos entre 2004 a 2016 y que fueron seleccionados de la Base Nacional de Datos sobre el Cáncer.PACIENTES:Identificamos pacientes con CCEA en estadíos I-III y que fueron tratados con radio-quimioterápia.PRINCIPALES MEDIDAS DE RESULTADOS:Se incluyeron factores socio-económicos tales como la raza, el tipo de seguro de salud, el ingreso familiar medio y el porcentaje de personas sin bachillerato de secundaria (SBS). Se investigó la asociación entre estos factores con el retraso en iniciar el tratamiento y la sobrevida global.RESULTADOS:Se identificaron un total de 24.143 pacientes que recibieron tratamiento para CCEA estadíos I-III. La mediana de edad fue de 60 años donde 70% eran de sexo femenino. La mediana del tiempo transcurrido desde el diagnóstico hasta el inicio del tratamiento fue de 33 días. Los pacientes residentes en zonas de código postal con ingresos medios más bajos, con un mayor porcentaje de individuos SBS y los pacientes con otro tipo de seguro gubernamental de salud, seguidos del seguro tipo Medicaid iniciaron el tratamiento solamente después de 60 días al diagnóstico inicial de CCEA. El análisis de Kaplan-Meier de la sobrevida mostró que el grupo de tratamiento tardío tuvo una peor supervivencia general comparada con el grupo de tratamiento precoz o temprano (98 frente a 125 meses; p <0,001).LIMITACIONES:No se dispone de información detallada sobre el tipo de radio-quimioterapia utilizada, ni sobre la finalización del tratamiento o la recurrencia, tampoco acerca de la sobrevida libre de enfermedad ni sobre las condiciones socio-económicas o aquellos factores de riesgo a nivel individual.CONCLUSIÓN:Los pacientes de comunidades con ingresos medios más bajos, con un nivel de educación limitado e inscritos en un seguro público tardaron mucho más tiempo en recibir el tratamiento prescrito. El nivel socio-económico más bajo también se asoció con una sobrevida global más baja. Los presentes resultados justifican mayor análisis y medidas mas importantes para mejorar el acceso a la atención en salud y poder afrontar esta disparidad. (Traducción-Dr. Xavier Delgadillo ).

Nanomaterials-based biosensor and their applications: A review.

A sensor can be called ideal or perfect if it is enriched with certain characteristics viz., superior detections range, high sensitivity, selectivity, resolution, reproducibility, repeatability, and response time with good flow. Recently, biosensors made of nanoparticles (NPs) have gained very high popularity due to their excellent applications in nearly all the fields of science and technology. The use of NPs in the biosensor is usually done to fill the gap between the converter and the bioreceptor, which is at the nanoscale. Simultaneously the uses of NPs and electrochemical techniques have led to the emergence of biosensors with high sensitivity and decomposition power. This review summarizes the development of biosensors made of NPssuch as noble metal NPs and metal oxide NPs, nanowires (NWs), nanorods (NRs), carbon nanotubes (CNTs), quantum dots (QDs), and dendrimers and their recent advancement in biosensing technology with the expansion of nanotechnology.

Anal Adenocarcinoma Arising From a Fistula-in-Ano: A Case Report.

Crohn's disease (CD) is an inflammatory disease that can affect any portion of the gastrointestinal tract (GIT). Although it can present with a number of complications, perianal fistulae are among the most common consequences in patients with CD. In very rare cases, these patients can develop fistula-associated anal adenocarcinoma (FAAA). In this case report, we discuss a 72-year-old man with a long-term history of CD complicated by perianal fistulae, which failed medical and surgical management, ultimately presenting with acute anal pain in the outpatient setting. The physical examination revealed a seton traversing through a fistula surrounded by circumferential granulation tissue suspicious for malignancy. A biopsy of the tissue confirmed grade 3 mucinous-type infiltrating adenocarcinoma of the perianal skin. The patient was diagnosed with an anal verge malignancy associated with a fistula in the context of long-standing CD, and MRI staging demonstrated a T3N1 lesion with potential left inguinal node involvement. He completed neoadjuvant chemo-radiotherapy using capecitabine for five weeks with minimal tumor response, and subsequently, an abdominoperineal resection (APR) was performed with patient discharge on the fifth post-procedure day. Post-operative chemotherapy with oxaliplatin/leucovorin/fluorouracil was administered with minimal complications. Although rare, this report demonstrates the importance of consistent follow-up and mitigation of risk factors in patients with CD, along with the significance of prompt multimodal treatment in the event of developing FAAA.

Open vs Minimally Invasive Approach for Emergent Colectomy in Perforated Diverticulitis.

BACKGROUND: Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting. OBJECTIVE: The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis. DESIGN: This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching. SETTINGS: Interventions were performed in hospitals participating in the national database. PATIENTS: Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat. MAIN OUTCOME MEASURES: Outcomes measures included length of stay and overall morbidity and mortality. RESULTS: Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates. LIMITATIONS: Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors. CONCLUSIONS: Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421. ABORDAJE ABIERTO VERSUS MNIMAMENTE INVASIVO PARA COLECTOMA DE EMERGENCIA EN DIVERTICULITIS PERFORADA: ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomía con anastomosis primaria. La cirugía mínimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el mínimamente invasivo para la diverticulitis perforada emergente.DISEÑO:Ésta fue una revisión retrospectiva de la base de datos de colectomía dirigida del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propensión.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomía emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus mínimamente invasivo se definieron por intención de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duración de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusión (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos mínimamente invasivos. El grupo mínimamente invasivo se sometió a operaciones más prolongadas y tuvo tasas más bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duración de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje mínimamente invasivo se asoció con tiempos quirúrgicos más prolongados, pero también con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duración de la estancia. No se detectaron diferencias en las tasas de fuga anastomótica, mortalidad, reintervención o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, pérdida de datos, falta de uniformidad, sesgo de selección y errores de codificación.CONCLUSIONES:La anastomosis primaria mínimamente invasiva emergente resulta en una estancia más corta y una disminución de la morbilidad a los 30 días en comparación con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y mínimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizás debido a una tasa de conversión del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND: Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement. OBJECTIVE: The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence. DESIGN AND SETTINGS: A retrospective review was performed at 3 university-affiliated teaching hospitals. PATIENTS: All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded. MAIN OUTCOME MEASURES: The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed. RESULTS: Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Impact of Abdominal Adipose Depots and Race on Risk for Colorectal Cancer: A Case-Control Study.

Visceral adipose tissue (VAT) but not subcutaneous adipose tissue (SAT) is associated with obesity-related diseases including colorectal cancer (CRC). Superficial SAT (SSAT) and deep SAT (DSAT), components of SAT, also appear to independently influence disease risk. These abdominal adipose tissues (AATs) are not extensively studied in connection with CRC and have not been explored in the United States despite known racial variations in body composition. We conducted a case-control study that compared associations between AAT with CRC risk and race of African-American (AA) and non-Hispanic white (NHW) men with incident CRC matched by age, body mass index, and race (N = 158, 79/group). Cross-sectional computed tomography images were used for assessment of AAT. Overall cases and controls had similar VAT areas (140 ± 192 vs 149 ± 152 cm2, P-value = 0.93); however, cases had lower SSAT than controls (88 ± 39 vs 112 ± 65 cm2, P < 0.01). Among controls, AA had significantly lower VAT (114 ± 168 vs 180 ± 167, P < 0.01) than NHW. Conditional logistic regression revealed that AA men with greater SSAT had lower odds for CRC (odds ratio [OR]: 0.24, 95% confidence interval [CI] 0.07-0.85). Our findings indicate that VAT does vary between cases and controls by race; however, this variation is not a risk factor for CRC. The negative association between CRC and SSAT in AA men warrants further investigation.

No clinical benefit from routine histologic examination of stapler doughnuts at low anterior resection for rectal cancer.

BACKGROUND: The aim of this study was to evaluate the clinical utility and cost-effectiveness of routine histologic examination of the doughnuts from stapled anastomoses in patients undergoing a low anterior resection for rectal cancer. METHODS: We performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at 3 institutions. Pathologic findings in the doughnuts and their impact on patient management were recorded. Tumor characteristics that may influence how often doughnuts were included in the pathology report were analyzed. An approximate cost of histologic examination of doughnuts was also calculated. RESULTS: A total of 412 patients (85%) had doughnuts included in their pathology reports. Two patients had cancer cells in their doughnuts, and both patients had a positive distal margin in their primary tumor specimen; 33 patients had benign findings in their doughnuts. Pathologic examination of the doughnut did not change clinical management in any patient. Patients with rectosigmoid tumors were less likely to have their doughnuts included in the pathology report compared to patients with low tumors (P = .003). Doughnuts were not bundled with the primary tumor specimen in 374 (77%) of our patients; in these patients, pathologic analysis of the doughnut added an additional cost of approximately $643 per specimen. CONCLUSION: This study demonstrates no clinical benefit in sending anastomotic doughnuts for histopathologic evaluation after performing a low anterior resection with a stapled anastomosis for rectal cancer. Overall cost may be decreased if doughnuts are not analyzed or if they are bundled with the primary tumor specimen.

Measuring Abdominal Circumference and Skeletal Muscle From a Single Cross-Sectional Computed Tomography Image: A Step-by-Step Guide for Clinicians Using National Institutes of Health ImageJ.

Diagnostic computed tomography (CT) scans provide numerous opportunities for body composition analysis, including quantification of abdominal circumference, abdominal adipose tissues (subcutaneous, visceral, and intermuscular), and skeletal muscle (SM). CT scans are commonly performed for diagnostic purposes in clinical settings, and methods for estimating abdominal circumference and whole-body SM mass from them have been reported. A supine abdominal circumference is a valid measure of waist circumference (WC). The valid correlation between a single cross-sectional CT image (slice) at third lumbar (L3) for abdominal SM and whole-body SM is also well established. Sarcopenia refers to the age-associated decreased in muscle mass and function. A single dimensional definition of sarcopenia using CT images that includes only assessment of low whole-body SM has been validated in clinical populations and significantly associated with negative outcomes. However, despite the availability and precision of SM data from CT scans and the relationship between these measurements and clinical outcomes, they have not become a routine component of clinical nutrition assessment. Lack of time, training, and expense are potential barriers that prevent clinicians from fully embracing this technique. This tutorial presents a systematic, step-by-step guide to quickly quantify abdominal circumference as a proxy for WC and SM using a cross-sectional CT image from a regional diagnostic CT scan for clinical identification of sarcopenia. Multiple software options are available, but this tutorial uses ImageJ, a free public-domain software developed by the National Institutes of Health.

Anal Adenocarcinoma: Outcomes in an Uncommon Malignancy.

Adenocarcinoma is an uncommon malignancy of the anal canal. Although it is recognized as an aggressive disease, optimal management and long-term outcomes are not well established. Patients diagnosed with anal adenocarcinoma were identified from a cancer database. Their charts were reviewed for patient and disease characteristics, management, and outcomes. Eighteen patient charts from 1997 to 2012 were reviewed. Nine patients presented with stage II disease, five with stage III, three with stage IV, and one was inadequately staged before chemoradiation. One patient refused treatment, one patient went straight to abdominoperineal resection, 13 patients underwent initial chemoradiation therapy, and three underwent palliative chemotherapy. Of the 13 patients who received neoadjuvant therapy, eight underwent subsequent radical resection; three progressed during neoadjuvant and became unresectable, one had complete pathologic response and was observed, and one did not complete neoadjuvant and was lost to follow-up. Two patients with stage II disease were disease free over eight years, and one was disease free after 26 months; four patients had persistent or recurrent local disease, and 10 developed metastatic disease. Seven patients died with disease at a median 16 months, and the other seven were alive with disease at a median follow-up of 10 months. Patients with anal adenocarcinoma present at advanced stages, and cure is rare. Although chemoradiation followed by abdominoperineal resection is the most common management strategy, the potential for curative resection and long-term disease free survival is minimal, regardless of stage at presentation.

Excess of proximal microsatellite-stable colorectal cancer in African Americans from a multiethnic study.

PURPOSE: African Americans (AA) have the highest incidence of colorectal cancer compared with other U.S. populations and more proximal colorectal cancers. The objective is to elucidate the basis of these cancer disparities. EXPERIMENTAL DESIGN: Of note, 566 AA and 328 non-Hispanic White (NHW) colorectal cancers were ascertained in five Chicago hospitals. Clinical and exposure data were collected. Microsatellite instability (MSI) and BRAF (V600E) and KRAS mutations were tested. Statistical significance of categorical variables was tested by the Fisher exact test or logistic regression and age by the Mann-Whitney U test. RESULTS: Over a 10-year period, the median age at diagnosis significantly decreased for both AAs (68-61; P < 0.01) and NHWs (64.5- 62; P = 0.04); more AA patients were diagnosed before age 50 than NHWs (22% vs. 15%; P = 0.01). AAs had more proximal colorectal cancer than NHWs (49.5% vs. 33.7%; P < 0.01), but overall frequencies of MSI, BRAF and KRAS mutations were not different nor were they different by location in the colon. Proximal colorectal cancers often presented with lymphocytic infiltrate (P < 0.01) and were diagnosed at older ages (P = 0.02). Smoking, drinking, and obesity were less common in this group, but results were not statistically significant. CONCLUSIONS: Patients with colorectal cancer have gotten progressively younger. The excess of colorectal cancer in AAs predominantly consists of more proximal, microsatellite stable tumors, commonly presenting lymphocytic infiltrate and less often associated with toxic exposures or a higher BMI. Younger AAs had more distal colorectal cancers than older ones. These data suggest two different mechanisms driving younger age and proximal location of colorectal cancers in AAs.

Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program.

BACKGROUND: Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions. METHODS: This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997-2008. RESULTS: Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2-1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks. CONCLUSIONS: Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.

Ligation of intersphincteric fistula tract: early results of a pilot study.

BACKGROUND: Transsphincteric fistulotomy is associated with a variable degree of fecal incontinence that is directly related to the thickness of the sphincter mechanism overlying the fistula. Staged fistulotomy with seton or the use of cutting seton designed to reduce the proportionate incontinence rates have failed to do so. This has resulted in attempts to find novel sphincter-sparing techniques in the past 2 decades including draining seton, fibrin sealant, anal fistula plug, dermal advancement, and endorectal advancement flaps. These operations have a variable success rates of 30% to 80% reported in the literature. OBJECTIVE: In 2007, Rojanasakul from Thailand demonstrated a novel technique, ligation of intersphincteric fistula tract, and reported a 94% success rate in a small series. Since then, a few other small cohorts of patients have been reported in the literature with success rates varying from 57% to 82%. An institutional review board-approved study was proposed to measure our results and compare them with the published data. DESIGN: This study was undertaken to evaluate the success of ligation of intersphincteric fistula tract procedures in a group of unselected transsphincteric fistulas deemed unsuitable for lay-open fistulotomy. SETTING: The procedure was performed in 3 different settings: a public institution, a major university hospital, and a large private hospital. PATIENTS: A total of 40 patients underwent 41 ligation of intersphincteric fistula tract procedures performed by 6 Board-certified colon and rectal surgeons. RESULTS: In a mean follow-up of 18 weeks, 74% of the patients achieved healing. In patients who underwent ligation of intersphincteric fistula tract as their primary procedure, the healing rate was 90%. The limitation of this study is its "case series" nature and the short mean follow-up period of 18 weeks. CONCLUSION: Ligation of intersphincteric fistula tract has had excellent success in transsphincteric fistulas in multiple small series. A larger number of patients and longer follow-up period are needed to validate the early favorable results.

Evaluation of midlevel and upper-level residents performing their first robotic-sutured intestinal anastomosis.

BACKGROUND: This study analyzed the experience of residents performing their first robotic intestinal anastomosis. METHODS: Eleven residents were tested. Participants performed 2 ex vivo hand-sewn suture lines followed by 3 robotic suture lines. RESULTS: The leak pressures in hand-sewn groups were 28.5 and 28.1 mm Hg; and 17.4, 7.6, and 21.4 mm Hg for 3 consecutive robotic groups. Completion time was longer in the robotic groups. The need for haptic assistance decreased between the first and third robotic drills. An analysis of the subjective evaluations also was performed. CONCLUSIONS: Complex hand-sewn tasks can be reproduced successfully by the residents using the robot-suturing technique. The quality of suturing and completion time improved over 3 consecutive exercises, although it did not reach the level of the hand-sewn suturing group.

A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents.

BACKGROUND: Robotic surgery offers all the advantages of laparoscopy with additional increased accuracy. The use of robotic surgery has increased in the past 5 years. It has proven particularly useful in complex surgical procedures such as intracorporeal intestinal anastomosis. As the prevalence of robotic surgery increases, so will the need for residents to be able to perform surgery using the robotic system. Our goal was to compare hand-sewn, laparoscopic, and robotic suturing techniques performed by midlevel residents using a porcine intestinal model. METHODS: Fifteen residents unfamiliar with the robotic suturing technique participated in performing an initial hand-sewn suture line and then were randomized with cross-over to laparoscopic or robotic suturing. Completion time, leak pressure, number of sutures per cm, and difficulty level were assessed. RESULTS: The mean leak pressure for hand-sewn, laparoscopic, and robotic suturing was 9.5, 3.2, and 11.4 mm Hg, respectively. The laparoscopic group had 6 and the robotic group had 1 suture line that was inadequate for testing. Suture breakage was common in the robotic group. The anastomosis was considered hard by 92% in the laparoscopic group versus 17% in the robotic group. The time it took to complete 1 cm of anastomosis was .9, 8.7, and 8.3 minutes for hand-sewn, laparoscopic, and robotic suturing, respectively. CONCLUSION: The robotic suture line performed by midlevel residents was superior to laparoscopy, although the time for anastomosis was equivalent.

Single-stapled double-pursestring anastomosis after anterior resection of the rectum.

BACKGROUND: Single-stapled double-pursestring technique for colorectal anastomosis to the mid-rectum or upper rectum is the most commonly used technique in the single institution reported here. The investigators evaluate single-stapled double-pursestring anastomosis after anterior resection of the rectum performed at a single institution. METHODS: Medical records of patients who underwent single-stapled double-pursestring anastomosis between January 2000 and May 2005 were analyzed to identify postoperative anastomotic complications. Patients with previous radiation, diverting stoma, coloanal, and hand-sewn and double-stapled anastomoses were excluded. The primary goal was to identify postoperative anastomotic complications. RESULTS: Of 160 patients, 153 (96%) no septic complications. One patient (.6%) developed anastomotic leak requiring diversion. Of the 4 patients with pelvic abscesses (2.5%), 2 were treated with antibiotics and 2 with computed axial tomography-guided drainage. CONCLUSIONS: Single-stapled double-pursestring anastomosis is reliable, with very low rates of leak, subsequent diversion, and pelvic abscess (.6%, .6%, and 2.5% respectively).

Early experience with stapled hemorrhoidectomy in the United States.

INTRODUCTION: We report the early results of patients treated with stapled hemorrhoidectomy, which has recently been introduced into the United States. METHODS: Sixty-eight patients with symptomatic hemorrhoids were treated at two institutions with the Proximate HCS Hemorrhoidal Circular Stapler supplied by Ethicon Endo-Surgery. Patients were prospectively evaluated for functional recovery and postoperative pain on a 1 to 10 scale. RESULTS: There were 45 (66 percent) males and 23 (34 percent) females with a mean age of 56 years and median duration of symptoms of 5 years. The mean operative time was 22.2 minutes. The operation was performed with spinal (50 percent), local (40 percent), or general (10 percent) anesthesia and as an outpatient (56 percent) or overnight admission (44 percent). Ninety-three percent of patients remained asymptomatic with a mean follow-up of 34 weeks, whereas the remaining 7 percent required either surgical excision or rubber band ligation for persistent symptoms. There was no mortality, new incontinence, fecal impaction, or persistent pain. The total morbidity was 19 percent, with urinary retention as the most common complication (12 percent). The mean pain score decreased from 3.6 on postoperative Day 1 to 1.4 at postoperative Day 7. Ninety-nine percent of patients made a complete functional recovery by postoperative Day 7. CONCLUSIONS: Stapled hemorrhoidectomy is safe, effective, and can be performed as an outpatient procedure with local or regional anesthesia. There seems to be minimal postoperative pain and early recovery, although a benefit over traditional hemorrhoidectomy needs to be proven in a randomized trial.