Setons in the surgical management of fistula in ano.

Seton techniques have been used in the successful management of fistula in ano for thousands of years. In particular, the cutting seton is useful for complex high anal fistula, and drainage setons may have a significant role in the treatment of sepsis related to Crohn's disease and in immunocompromised patients.

Totally stapled restorative proctocolectomy.

BACKGROUND: Totally stapled restorative proctocolectomy (TSRP) has simplified ileoanal pouch surgery but few reports exist concerning experience with the technique. A retrospective study of operative and functional data in a consecutive series of patients undergoing TSRP was undertaken. METHODS: TSRP with J pouch formation was attempted in 103 patients between 1988 and 1995 (for ulcerative colitis (87 patients), familial adenomatous polyposis coli (nine), slow transit constipation (six) and hereditary non-polyposis colorectal cancer (one). Three technical failures resulted in 100 patients available for assessment. Case notes were reviewed together with functional assessment by clinical interview and/or postal questionnaire. RESULTS: Median operating time was 200 min, intraoperative blood loss 360 ml and hospital stay 12 days. There were no operative deaths. All but five patients (95 per cent) had loop ileostomy formation with subsequent reversal. There were 29 complications, six of which required further surgical intervention. Six pouches were excised and two patients had a temporary defunctioning ileostomy. Five patients were rediagnosed as having Crohn's disease, of whom four underwent subsequent pouch excision. Pouchitis (in the absence of Crohn's disease) occurred in eight patients (8 per cent). In 60 patients with at least 12 months of established function, median day and night stool frequencies were 5 and 1 respectively. Functional evaluation in 49 patients (82 per cent) revealed regular use of antidiarrhoeal medication in 21, urgency in 17, and total continence by day and night in 37 and 35 respectively. Fifty-three patients (88 per cent) were satisfied with the overall long-term outcome. CONCLUSION: TSRP is safe, has simplified a technically difficult operation and gives good long-term functional results.

Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano.

PURPOSE: The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a risk of fecal incontinence. We have assessed the functional impact of treating patients with a complex fistula-in-ano by a cutting seton fistulotomy technique that preserves the internal sphincter. METHODS: The operative steps consisted of initial eradication of sepsis, identification of the internal and external openings of the fistula tract, excision of the fistula tract with anal canal mucosa, and insertion of a cutting silk seton around both the internal and external sphincters. In this way open drainage of the intersphincteric space was avoided, and integrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradication and effect on fecal continence was assessed in 27 patients (15 males) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery. RESULTS: The fistula was cured in 26 patients (96 percent) with no reports of altered continence at the time of discharge from outpatient review. Recurrence developed in one patient (4 percent) in whom hidradenitis suppurativa was subsequently diagnosed. All four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently undergone proctectomy for severe perianal and rectal Crohn's involvement. Long-term follow-up revealed three patients (19 percent, all rectovaginal fistulas) who experienced a deterioration in continence after discharge. CONCLUSIONS: Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are effective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.

Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus.

The role of laparoscopy in determining suitability for resection was prospectively evaluated in 244 patients with cancer of the gastric cardia and oesophagus. Laparoscopy enabled detection of inoperable disease in 92 patients (38 per cent), several of whom had more than one contraindication to surgery. Hepatic metastases (n = 75, 31 per cent), extensive peritoneal (n = 25, 10 per cent) or lymph node involvement (n = 5, 2 per cent) and direct invasion of the liver or colon (n = 5, 2 per cent) were considered contraindications to surgery. Laparoscopy was poorly tolerated in a further 11 (5 per cent) patients, who were not considered suitable for resection. Extra-abdominal metastatic disease was detected in 17 patients who appeared normal at laparoscopy, and a further six patients refused surgery. The remaining 118 patients underwent laparotomy with a view to resection which was successful in 85 (72 per cent). Laparoscopy thus prevented ill-advised laparotomy in 103 patients (42 per cent), either because of extensive intra-abdominal disease or poor tolerance to anaesthesia. Laparoscopy may be a valuable investigation when used to assess the feasibility of resection.

Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis.

BACKGROUND: The introduction of surgical stapling instruments has widened the use of restorative proctocolectomy. Too high a distal transection of the rectum can, however, produce a retained rectal stump, which may cause symptoms. A study of the operative and functional data in a consecutive series of patients undergoing salvage surgery for retained rectal stump was undertaken. METHODS: Twenty-five patients referred between January 1990 and September 2000 for pouch dysfunction were identified as having a retained rectal stump. Twenty-two underwent abdominoanal revision. The hospital notes were reviewed and function was assessed during outpatient visits, by postal questionnaire and by telephone interview. RESULTS: Median operating time was 225 (range 170-340) min and median hospital stay was 15 (range 8-48) days. There was no operative death. Five pouches were excised. Seventeen patients were available for functional assessment. Median follow-up was 22.5 (range 4-114) months. Median 24-h frequency before and after operation was 12 (range 4-20) and 6 (range 3-12) respectively, and median night-time frequency was 4 (range 0-8) and 0.5 (range 0-4) respectively. Fifteen patients reported marked subjective improvement in pouch function and quality of life. CONCLUSION: Major revisional surgery for symptomatic retained rectal stump after restorative proctocolectomy with stapled anastomosis was successful in 15 of 22 patients. These results are worse than the outcome following first-time restorative proctocolectomy with anastomosis constructed at the anal level. Pouch-rectal anastomosis should be avoided.

Factors that predict complications after construction of a stoma: a retrospective study.

OBJECTIVE: To find out our incidence of complications of stoma surgery and identify variables that predict outcome. DESIGN: Retrospective study. SETTING: Teaching hospital, Scotland. SUBJECTS: All 121 patients who had 126 stomas constructed during 1996. INTERVENTIONS: Follow up until the end of 1999. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There were 64 men and 57 women, median age 58 years, range 16-83. Forty-three stomas were constructed for malignancy (34%). Forty-two stomas were raised during emergency operations (33%). Colorectal surgeons created 96 stomas (76%). Sixty-one of 92 potentially reversible stomas were closed (66%). Two patients died (2%) perioperatively. Overall stoma-related morbidity was 68% (n = 85). The rate of major stoma-related complications was 26% (n = 33). Nine major complications resulted in a reoperation rate of 7%. On univariate analysis, age, American Society of Anesthesiologists (ASA) grade, and surgeon's speciality were significant predictive variables of major stomal complications (p < or = 0.002, 0.02, and 0.05 respectively). Multivariate analysis showed that the age of the patient was the only factor that independently influenced the outcome of stoma surgery (p < or = 0.001). CONCLUSIONS: Optimising the perioperative health status of the patients, particularly the elderly, may reduce morbidity. The results also support specialist surgical care of patients undergoing stomal surgery.