Cutaneous Crohn's disease after proctocolectomy for medically refractory colonic Crohn's disease: a case series and review of the literature.

Background: Cutaneous Crohn's disease (CCD), also known as metastatic Crohn's disease (CD), is one of the rarest and most challenging cutaneous manifestations of CD. It is characterized by non-caseating granulomatous inflammation of the skin at sites that are non-contiguous with the gastrointestinal (GI) tract. Diagnosis of CCD needs a high clinical suspicion since morphological presentation varies widely and lacks an apparent correlation to the activity of the luminal CD. The onset of CCD in patients without active GI CD is a particularly understudied phenomenon. Methods: We present a case series of a unique patient group who developed CCD while in remission from a luminal CD perspective, mainly after a proctocolectomy for Crohn's colitis. We also provide a literature review and summary of case reports of CCD after proctocolectomy. Results: Our 4 adult patients diagnosed with CCD after proctocolectomy presented herein, were successfully treated with high-dose corticosteroids, followed by biologic therapy. Furthermore, a comprehensive review of CCD is provided regarding its pathogenesis, clinical presentation, differential diagnosis, and the evidence behind the available treatments. Conclusions: CCD should be considered in any CD patient presenting with skin lesions regardless of their disease activity status and history of proctocolectomy. The treatment remains challenging; biologics remain the cornerstone and a multidisciplinary approach is recommended. Larger randomized clinical trials are essential to determine the optimal treatment protocol and to improve outcomes.

Serum Depletion of Complement Component 5a Is Associated With Increased Inflammation and Poor Clinical Outcomes in Patients With Perianal Fistulas.

BACKGROUND: Persistent disease is a significant issue in the management of perianal fistulas, with up to 50% of patients requiring additional treatment after surgery. OBJECTIVE: This study aimed to identify a novel prognostic modality in hopes of risk-stratifying patients for persistent disease following corrective surgery. DESIGN: This was a retrospective study based on prospectively collected data using a combination of histopathology, high-throughput proteomic arrays, and ELISA-based methods. SETTINGS: This study used data obtained from patients who underwent corrective surgery for perianal fistulas at the University of Illinois Hospital between June 2019 and July 2020. PATIENTS: A cohort of 22 consecutive patients who had corrective surgery for perianal fistulas were included in this study. The patients were divided into 2 groups: those with resolving fistulas (N = 13) and those with persisting fistulas (N = 9). MAIN OUTCOME MEASURES: Nonresolving fistulas were determined by disease representation within 2 months of corrective surgery. RESULTS: Serum samples from patients with persistent perianal fistulas displayed a consistent decrease in the expression of complement pathway component C5a compared with either healthy controls or patients with resolving forms of disease. This was paralleled by an increase in the fistula expression of C5a and an associated increase in tissue infiltrating leukocytes and interleukin-1ß expression. LIMITATIONS: This study was limited by its retrospective design, relatively small sample size, and single-center data analysis. CONCLUSIONS: These results suggest that C5a is modestly depleted in patients with nonresolving forms of disease and traffics to the site of tissue damage and inflammation. Accordingly, serum C5a warrants continued investigation as a prognostic biomarker and predictor of recurrence in patients presenting with perianal fistulas. See Video Abstract at http://links.lww.com/DCR/B982 . LA DEPLECIN SRICA DEL COMPONENTE A DEL COMPLEMENTO SE ASOCIA CON UN AUMENTO DE LA INFLAMACIN Y MALOS RESULTADOS CLNICOS EN PACIENTES CON FSTULAS PERIANALES: ANTECEDENTES:La persistencia de la enfermedad es un problema significativo en el manejo de las fístulas perianales, presente hasta en el 50 % de los pacientes después de la cirugía y que requieren tratamiento adicional.OBJETIVO:DISEÑO:Se trata de un estudio retrospectivo basado en datos recolectados prospectivamente usando una combinación de histopatología, arreglos proteómicos de alto rendimiento y métodos basados en ELISA.ENTORNO CLÍNICO:Este estudio utilizó datos de pacientes que se sometieron a cirugía correctiva por fístulas perianales en el Hospital de la Universidad de Illinois entre junio de 2019 y julio de 2020.PACIENTES:Se incluyó en este estudio una cohorte de 22 pacientes consecutivos que se sometieron a cirugía correctiva de fístulas perianales. Los pacientes se dividieron en 2 grupos: aquellos con fístulas en resolución (N = 13) y aquellos con fístulas persistentes (N = 9).PRINCIPALES MEDIDAS DE VALORACIÓN:Las fístulas que no se resuelven fueron determinadas por la reaparición de la enfermedad dentro de los 2 meses posteriores a la cirugía correctiva.RESULTADOS:Las muestras de suero de pacientes con fístulas perianales persistentes mostraron una disminución constante en la expresión del componente C5a de la vía del complemento en comparación con controles sanos o pacientes con formas de resolución de la enfermedad. Esto fue paralelo a un aumento en la expresión de C5a en la fístula y un aumento asociado en los leucocitos que se infiltran en el tejido y la expresión de IL-1ß.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo, tamaño de muestra relativamente pequeño y análisis de datos de un solo centro.CONCLUSIONES:Estos resultados sugieren que C5a se reduce moderadamente en pacientes con formas de enfermedad que no se resuelven y se desplaza al sitio del daño tisular e inflamación. En consecuencia, el C5a sérico justifica una investigación continua como biomarcador pronóstico y predictor de recurrencia en pacientes que presentan fístulas perianales. Consulte Video Resumen en http://links.lww.com/DCR/B982 . (Traducción- Dr. Ingrid Melo ).

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.

Evaluation of a Minimally Invasive Bipolar Coagulation System for the Treatment of Grade I and II Internal Hemorrhoids.

BACKGROUND: Hemorrhoids are common and affect mainly the young and middle-aged populations. Current guidelines recommend treating grade I and II hemorrhoids with office-based procedures. These therapies usually require multiple applications. Hemorrhoid energy therapy treats the hemorrhoids at 1 treatment session. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of hemorrhoid energy therapy. DESIGN: This was a prospective pilot study evaluating patients with symptomatic grade I and II internal hemorrhoids. SETTINGS: The study was conducted at a tertiary academic center. PATIENTS: Patients over the age of 18 years with chronic, symptomatic grade I and II internal hemorrhoids who failed 2 weeks of conservative therapy were enrolled between July 2015 and January 2019. Exclusion criteria included patients with grade III or IV internal hemorrhoids, external hemorrhoids, nonhemorrhoidal GI bleeding, active proctitis, and IBD. INTERVENTIONS: Hemorrhoid energy therapy was administered in clinic, and 2 postprocedure visits were completed. A pretreatment hemorrhoid symptom score was obtained from each patient. A visual analog score was assessed posttreatment. MAIN OUTCOME MEASURES: The primary end point was to evaluate the effect of hemorrhoid energy therapy on hemorrhoid symptoms and its safety. The secondary end point was evaluation of postprocedural pain. RESULTS: A total of 35 patients were enrolled. The mean duration of hemorrhoid symptoms was 3.3 ± 6.4 years, and rectal bleeding and hemorrhoidal prolapse were the most common symptoms. After the procedure, patient hemorrhoid symptom scores decreased from mean 5.5 to 1.4. The mean immediate postprocedural visual analog score was 2.4 ± 2.1 and decreased to <1.0 after 14 days. LIMITATIONS: The limitations include lack of comparative groups, single-center design, and small cohort of patients. CONCLUSIONS: The application of hemorrhoid energy therapy in the treatment of grade I and II internal hemorrhoids is safe and results in reduction of symptoms, low rate of short-term complications, and minimal pain. See Video Abstract at http://links.lww.com/DCR/B491. EVALUACIÓN DE UN SISTEMA DE COAGULACIÓN BIPOLAR MÍNI-INVASIVA PARA EL TRATAMIENTO DE HEMORROIDES INTERNAS GRADOS I Y II: La enfermedad hemorroidal es muy común y afecta principalmente poblaciones jóvenes y de mediana edad. Las guías actuales recomiendan tratar las hemorroides de grado I y II con procedimientos en el consultorio. Estos tratamientos suelen requerir múltiples aplicaciones. La aplicación de energía para tratar las hemorroides requiere de una sola sesión.Evaluar la seguridad y eficacia del tratamiento hemorroidal con una fuente de energía.Estudio piloto prospectivo que evalúa los pacientes con hemorroides internas de grado I y II sintomáticas.El estudio se realizó en un centro académico terciario.Entre julio de 2015 y enero de 2019 se inscribieron pacientes mayores de 18 años con hemorroides intomáticas internas crónicas grado I y II que fracasaron luego de 2 semanas de tratameinto conservador. Los criterios de exclusión incluyeron pacientes con hemorroides internas de grado III o IV, hemorroides externas, sangrado de orígen gastrointestinal no hemorroidal, proctitis activa y enfermedad inflamatoria intestinal.Se realizó la aplicación de energía sobre las hemorroides en el consultorio y se completó el procedimiento con dos visitas posteriores. Se obtuvo una puntuación analógica de síntomas hemorroidarios en cada paciente antes del tratamiento. Se evaluó la puntuación analógica visual luego del procedimiento.El principal criterio final fué evaluar el efecto de la terapia energética hemorroidaria con relación a los síntomas y la seguridad del dispositivo. El segundo criterio final fué el evaluar el dolor posoperatorio.Se registraron un total de 35 pacientes. La duración media de los síntomas hemorroidarios fué de 3,3 ± 6,4 años, el sangrado rectal y el prolapso hemorroidal fueron los síntomas más frecuentes. Después del procedimiento, las puntuaciones de los síntomas hemorroidarios disminuyeron en una media de 5,5 a 1,4. La puntuación analógica visual media inmediatamente posterior al procedimiento fue de 2,4 ± 2,1 y disminuyó a <1 después de 14 días.Las limitaciones incluyen la falta de grupos comparativos, el diseño de un solo centro y una pequeña cohorte de pacientes.La aplicación de energía como tratamiento de la enfermedad hemorroidal interna grado I y II es segura y da como resultados la reducción de los síntomas, una baja tasa de complicaciones a corto plazo y mínimo dolor. Consulte Video Resumen en http://links.lww.com/DCR/B491. (Traducción-Dr Xavier Delgadillo).

Morbidity and Mortality of Total Pelvic Exenteration for Malignancy in the US.

BACKGROUND: Total pelvic exenterations (TPEs) for malignancies are complex operations often performed by multidisciplinary teams. The differences among primary cancer for TPE and multicentered results are not well described. We aimed to describe TPE outcomes for different malignant origins in a national multicentered sample. METHODS: Patients from the National Surgical Quality Improvement Program (NSQIP) database who underwent TPE between 2005 and 2016 for all malignant indications (colorectal, gynecologic, urologic, or other) were included. Chi square and Kruskal-Wallis tests were used to compare patient characteristics by primary malignancy. Multivariate logistic and linear regression models were used to determine factors associated with any 30-day Clavien-Dindo grade 3 or higher complication, length of hospital stay (LOS; days), 30-day wound infection, and 30-day mortality. RESULTS: Overall, 2305 patients underwent TPE. Indications for surgery included 33% (749) colorectal, 15% (335) gynecologic, 9% (196) other, and 45% (1025) urologic malignancies. Median LOS decreased from 10 to 8 days during the study period (p < 0.001), 36% were males, and 50% required blood transfusion. High-grade complications occurred in 15% of patients and were associated with bowel diversion [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.4], disseminated cancer (OR 1.8, 95% CI 1.4-2.3), and gynecologic cancers (OR 2.9, 95% CI 1.8-4.7). Mortality was 2% and was associated with disseminated cancer (OR 2.2, 95% CI 1.1-4.3) and male sex (OR 2.4, 95% CI 1.3-4.4). CONCLUSIONS: TPE is associated with high rates of complications, however mortality rates remain low. Preoperative and perioperative outcomes differ depending on the origin of the primary malignancy.

Acute diverticulitis in renal transplant patients: should we treat them differently?

BACKGROUND: Current guidelines suggest that transplant patients with acute diverticulitis should be managed aggressively with early operative intervention to reduce morbidity and mortality. This study compared the treatment choices and clinical outcomes between renal transplant patients and immunocompetent patients with acute diverticulitis. METHODS: A retrospective review was performed of all patients who were admitted with acute diverticulitis between 2002 and 2015 at a single academic institution. Patient demographics, comorbidities, physiologic and radiologic disease severity, management, and disease-specific outcomes were recorded and compared between renal transplant patients and immunocompetent patients. Predictors of complications also were analyzed. RESULTS: In the study, 20 renal transplant patients and 134 immunocompetent patients were admitted for acute diverticulitis and were followed for a median time of 36 and 40 months, respectively. Patient demographics were similar between the groups. Transplant patients had significantly more comorbidities. Overall, there were no differences in physiologic disease severity or rates of elective or urgent operation, ostomy, permanent ostomy, duration of stay, 30-day readmission, disease recurrence or disease-specific complications, organ failure, or death. Among patients with complicated disease, renal transplant patients were significantly more likely to undergo an urgent operation and had more complications. On multivariate analysis, undergoing operative therapy remained the sole predictor of complications. CONCLUSION: Nonoperative management of renal transplant patients who present with uncomplicated diverticulitis is safe as outcomes are similar to immunocompetent patients. However, the optimal management of renal transplant patients with complicated diverticulitis remains unclear as both treatment choices and complication rates differed from immunocompetent patients.

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.

Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review.

Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.

Biliary Stent Migration: A Rare Cause of a Bladder Stone.

Our patient presented with dysuria and pneumaturia without any prior urologic instrumentation. History included choledocolithiasis requiring endoscopic retrograde cholangiopancreatography and biliary stenting. Imaging showed a large bladder stone. The patient was taken to surgery and found to have diverticulitis. The sigmoid was resected and the bladder was found to have a small fistula tract. The bladder was opened and a large calculus was identified and extracted. The stone was opened and found to contain a biliary stent. Although biliary stenting is generally considered safe, migration can occur. This is the only report of biliary stent migration into the bladder and subsequent stone formation.

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.

Bio-Thiersch as an Adjunct to Perineal Proctectomy Reduces Rates of Recurrent Rectal Prolapse.

BACKGROUND: The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence. OBJECTIVE: The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone. DESIGN: A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed. SETTINGS: Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital. PATIENTS: Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared. INTERVENTIONS: All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct. MAIN OUTCOME MEASURES: The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented. RESULTS: Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05). LIMITATIONS: This study was limited by nature of being a retrospective review. CONCLUSIONS: Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Sacral Nerve Stimulation in the Treatment of Bowel Disorders.

Defecation problems occur in patients of all ages, but are more prevalent in the elderly, postpartum women, and patients with chronic and debilitating medical conditions. Most of the time, these problems respond to medical therapy and nonsurgical options, but it is not uncommon for patients to require surgical intervention. Sacral nerve stimulation (SNS) presents an alternative for patients with bowel dysfunction combining proven therapeutic benefits and limited surgical risks. Here we describe the common indications for SNS, patient selection, technical details of the procedure, published outcomes, and complications that can arise. Based on our review, SNS is an effective treatment option for fecal incontinence and may reduce the patients' clinical symptoms and help restore their quality of life. Future research studies may expand the role of this modality for other bowel disorders.

Impaired rectal sensation at anal manometry is associated with anal incontinence one year after primary sphincter repair in primiparous women.

PURPOSE: This study investigates the association between endoanal ultrasonography and anorectal manometry in relation to anal incontinence after primary repair of obstetric sphincter injury in primiparous, premenopausal women. METHODS: The study population of this nested case-control study comprised 108 women who had previously been part of a randomized controlled trial comparing immediate with delayed primary repair of obstetric sphincter injuries, and who had been evaluated by anorectal manometry and endoanal ultrasound 1 year after their repair. Twenty cases and 88 controls were defined. Cases were defined as having a score greater than 2 on the Pescatori incontinence scale. Controls had a score of 2 or less. Ten obstetric, 9 ultrasonographic, and 7 manometric variables were studied. RESULTS: Of the manometric variables, volume of first sensation and volume of first urge proved to be associated with anal incontinence at univariate statistical analysis. Volume of first sensation remained independently associated with anal incontinence after multivariate analysis. In addition, age, degree of tear, duration of second stage of labor, and a distal scar at ultrasound proved to be independently associated with anal incontinence. CONCLUSIONS: Impaired rectal sensation at anorectal manometry and a distal scar at endoanal ultrasonography are associated with anal incontinence 1 year after primary sphincter repair in primiparous women. Additional studies need to evaluate whether these findings are associated with increased risk of anal incontinence in women that are continent 1 year after primary repair.

Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations.

PURPOSE: Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS: A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS: Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS: Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Natural progression of anal incontinence after childbirth.

INTRODUCTION AND HYPOTHESIS: The aim of work is to study the natural progression of anal incontinence (AI) in women 10 years after their first delivery and to identify risk factors associated with persistent AI. METHODS: A prospective cohort study of 304 primiparous women with singleton, cephalic delivery giving vaginal childbirth in 1995. Questionnaires distributed and collected at delivery, 9 months, 5 years and 10 years after, assessing anorectal symptoms, subsequent treatment, and obstetrical events. RESULTS: Women, 246 of 304, answered all questionnaires (81%). Thirty-five of 246 (14%) had a sphincter tear at the first delivery. One hundred ninety-six of 246 (80%) women had additional vaginal deliveries and no caesarean sections. The prevalence of AI at 10 years after the first delivery was 57% in women with a sphincter tear and 28% in women, a nonsignificant increase compared to the 5-year follow-up. Women who sustained a sphincter tear at the first delivery had an increased risk of severe AI (RR 3.9, 95% CI 1.3-11.8). Neither age, nor subsequent deliveries added to the risk. Severe AI at baseline and 5 years after delivery were independently strong predictors of severe AI at 10 years (RR 12.6, CI 3.3-48.3, and RR 8.3, CI 3.9-17.8, respectively). CONCLUSION: Persistent anal incontinence 10 years after the first parturition is frequent and sometimes severe, especially if vaginal delivery was complicated by an anal sphincter disruption.

Metabolomic characterization of human rectal adenocarcinoma with intact tissue magnetic resonance spectroscopy.

PURPOSE: This study was designed to test whether metabolic characterization of intact, unaltered human rectal adenocarcinoma specimens is possible using the high-resolution magic angle spinning proton (1H) magnetic resonance spectroscopy technique. METHODS: The study included 23 specimens from five patients referred for ultrasonographic staging of suspected rectal cancer. Multiple biopsies of macroscopically malignant rectal tumors and benign rectal mucosa were obtained from each patient for a total of 14 malignant and 9 benign samples. Unaltered tissue samples were spectroscopically analyzed. Metabolic profiles were established from the spectroscopy data and correlated with histopathologic findings. RESULTS: Metabolomic profiles represented by principle components of metabolites measured from spectra differentiated between malignant and benign samples and correlated with the volume percent of cancer (P = 0.0065 and P = 0.02, respectively) and benign epithelium (P = 0.0051 and P = 0.0255, respectively), and with volume percent of stroma, and inflammation. CONCLUSIONS: Magnetic resonance spectroscopy of rectal biopsies has the ability to metabolically characterize samples and differentiate between pathological features of interest. Future studies should determine its utility in in vivo applications for non-invasive pathologic evaluations of suspicious rectal lesions.

Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery.

OBJECTIVE: The objective of the study was to compare the prevalence of incontinence disorders in relation with spontaneous vaginal delivery or cesarean section. STUDY DESIGN: Two hundred women with spontaneous vaginal deliveries only were compared with 195 women with cesarean deliveries only 10 years after first delivery. RESULTS: When compared with cesarean section, vaginal delivery was associated with an increased frequency of stress urinary incontinence (P = .006) and an increased use of protective pads (P = .008) as well as an increased frequency of fecal urgency (P = .048) and gas incontinence (P = .01). At multivariate regression analysis, mode of delivery showed no significant association with incontinence symptoms other than an increased risk for flatus incontinence in women with a history of obstetric anal sphincter injury (odds ratio 3.1; 95% confidence interval, 1.5 to 8.9). CONCLUSION: Incontinence symptoms are more common following spontaneous vaginal delivery when compared with cesarean section 10 years after first delivery. However, cesarean section is not associated with a major reduction of anal and urinary incontinence.

Effects of hysterectomy on bowel function: a three-year, prospective cohort study.

PURPOSE: This study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence. METHODS: In this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics. RESULTS: The bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05-2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up. CONCLUSIONS: Neither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.