Outcomes of colostomy takedown following Hartmann's procedure: successful restoration of continuity comes with a high risk of morbidity.

AIM: Restoration of bowel continuity following a Hartmann's procedure is a major surgical undertaking associated with significant morbidity. The aim of this study was to review the authors' experience with Hartmann's reversal. METHOD: This was a retrospective review of consecutive patients from institutional databases who were selected to undergo open or laparoscopic Hartmann's reversal at two tertiary academic referral centres and a public safety net hospital (2010-2019). The main outcome measure was the rate of successful stoma reversal. Secondary outcomes included 30-day postoperative outcomes and procedural details. RESULTS: One hundred and fifty patients underwent attempted reversal during the study period, which was successful in all but three patients (98%). Patients were 59% Hispanic and 73% male, with a mean age of 48.7 ± 14.1 years, mean American Society of Anesthesiologists classification of 2.2 ± 0.6 and mean body mass index (BMI) of 28.6 ± 5.3 kg/m2 , with 39% of patients having a BMI > 30 kg/m2 . The mean time interval between the index procedure and reversal was 14.4 months, 53% of the index cases were performed at outside institutions and the most common index diagnoses were diverticulitis (54%), abdominal trauma (16%) and colorectal malignancy (15%). In 22% of cases a laparoscopic approach was used, with 42% of these requiring conversion to open. Proximal diverting stomas were created in 32 patients (21%), of which 94% were reversed. The overall morbidity rate was 54%, comprising ileus (32%), wound infection (15%) and anastomotic leak (6%), with a major morbidity rate (Clavien-Dindo ≥ 3) of 23%. CONCLUSION: Hartmann's reversal remains a highly morbid procedure. Our results suggest that operative candidates can be successfully reversed, but there is significant morbidity associated with restoration of intestinal continuity, particularly in obese patients. A laparoscopic approach may decrease morbidity in selected patients but such cases have a high conversion rate.

Current Advances in Colorectal Surgery in Latin America: Insights on the 2019 Latin American Association of Coloproctology Congress.

The Latin American Association of Coloproctology (ALACP) held its 26 biennial congress in conjunction with the 44 annual meeting of the Mexican Society of Surgeons of the Rectum, Colon, and Anus (SMCRCA). The meeting took place October 2 to 5, 2019, in Cancun, Mexico. Twenty-eight international professors from North America, Europe, and Asia participated alongside 62 speakers from all of Latin America and the Caribbean. More than 400 participants converged from North, Central, and South America; the Caribbean; Europe; and Asia. Participants included 63 residents from Latin America, Europe, and Asia who contributed an unprecedented number of poster presentations. The meeting was highly interactive, consisting of 1 day of 5 highly dynamic workshops and 3 days of plenary sessions covering a broad spectrum of topics within colorectal surgery. Authoritative lectures by world leaders were punctuated by debates, panel discussions, and presentations of problem cases that delighted the audience. ALACP accomplished transformative changes in its general assembling meetings set into motion by its 26 presidency. These accomplishments included the first reformation of its bylaws in over a quarter century, an official affiliation with Diseases of the Colon & Rectum, and the relocation of the ALACP Secretariat General from Rio de Janeiro to Mexico City.

Idiopathic Pruritus Ani and Acute Perianal Dermatitis.

This article reviews the etiologies, pathophysiology, clinical evaluation, and treatment of idiopathic pruritus ani and perianal dermatitis. It underscores a practical approach to each of these common proctologic conditions.

Mycotic and Bacterial Infections.

This article reviews the salient clinical features, evaluation, and treatment of mycotic and bacterial infections of the perianal and contiguous zones of the human body.

Systemic and Autoimmune Diseases.

This article reviews the clinical features of systemic and autoimmune diseases affecting the perianal region and its surrounding integumentary structures.

Selected Techniques of Anal Fistula Surgery from Antiquity Through the Early 20th Century Illustrated.

This article highlights surgical approaches to the surgical treatment of anal fistula from antiquity to the early 20th century. Primary translations and other authoritative commentaries on the subject are included. Selected surgical techniques have been reconstructed and illustrated in contemporary interpreted images.

Perineal injuries at a large urban trauma center: injury patterns and outcomes.

The purpose of this study was to describe the characteristics of this unique patient population, their clinical presentations, and outcomes. The Los Angeles County and University of Southern California Medical Center Trauma Registry was used to retrospectively identify patients who sustained perineal injuries. Information included gender, age, vital signs, trauma scores, mechanisms of injury, studies performed, surgeries performed, and outcomes. Pediatric patients and injuries related to obstetric trauma were not included. Sixty-nine patients were identified between February 1, 1992 and October 31, 2005. One patient died on arrival; 85 per cent (58 of 68) were males, mean age was 30 +/- 12 years, and there was a penetrating mechanism in 56 per cent. Vital signs on admission were systolic blood pressure 119 +/- 33 mmHg, heart rate 94 +/- 27 beats/minute, and respiratory rate 20 +/- 6 breaths/min. Glasgow Coma Scale (GCS) was 13 +/- 3, Revised Trauma Score (RTS) was 7.2 +/- 1.5, and Injury Severity Score (ISS) was 11 +/- 12. CT scan was obtained for 23 (33%) patients. Lower extremity fractures were 35 per cent and pelvic fractures 32 per cent. The most common surgery was débridement and drainage, diversion with colostomy in five patients (7%). Overall mortality was 10 per cent. Mortality group mean scores were: GCS, 6; RTS, 5.74; and ISS, 34. The survival group mean scores were: GCS, 14; RTS, 7.7; and ISS, 8. There was a statistically significant association between mortality and GCS, RTS, and ISS scores (P < 0.001). Most patients with perineal injuries (93%) can be managed without colostomy. Associated injuries are not uncommon, particularly bony fractures. Mortality is mostly the result of exsanguination related to associated injuries.

Changing concepts in the pathogenesis, evaluation, and management of solitary rectal ulcer syndrome.

The purpose of this study was to assess the impact of new technology on both the understanding of the underlying pathophysiology and treatment of solitary rectal ulcer syndrome (SRUS). This study is a retrospective review of patients with a histologic diagnosis of SRUS (1993 to 2007) complimented with a prospective database of those patients studied with defecography and dynamic pelvic MRI. Thirty patients were available for evaluation. A polyp or mass was present in 74 per cent. Ulcers were found in only 23 per cent. All 12 patients undergoing defecography demonstrated rectorectal intussusception. Dynamic MRI of the pelvis revealed pronounced anorectal redundancy and lack of mesorectosacral fixation with mild to severe pelvic floor descent in all four patients studied. Fiber with or without stool softeners was the initial treatment in all patients with resolution of symptoms in 65 per cent. One patient with refractory symptoms underwent a stapled transanal rectal resection with complete resolution of symptoms. Occult rectorectal intussusception appears to be the operant anatomic pathology in SRUS. Anorectal redundancy with lack of mesorectosacral fixation may contribute to the process. All patients should be studied with defecography and dynamic MRI. Stapled transanal rectal resection may offer a promising surgical option.

Operative management of diverticulitis in a tertiary care center.

BACKGROUND: Diverticulitis has become a medically managed disease process; the indications and timing of surgical intervention have evolved. METHODS: We retrospectively reviewed all patients who underwent surgical intervention due to diverticular disease by the Division of Colon and Rectal Surgery from 2012 to 2014. RESULTS: Ninety-eight surgeries were performed. Indications included colovesicular fistula, multiple recurrences of diverticulitis, medically refractory diverticulitis, stricture, abscess, colocutaneous fistula, and colovaginal fistula. Average length of stay was 5.7 ± 5.9 days (range, 1 to 51). Eighteen patients (18%) required an ostomy. Postoperative complications occurred in 18% of patients, including anastomotic leak (3.3%), wound infection (7.1%), acute kidney injury (5.1%), and urinary tract infection (2.0%). Thirty-day readmission rate was 7.2%; unplanned 30-day reoperation rate was 3.1%. There were no deaths. CONCLUSIONS: The type of patient undergoing surgery for diverticulitis has changed, with selection bias toward chronic, advanced disease due to the proliferation of medical management strategies.

Intraoperative physical diagnosis in the management of anal fistula.

This report reviews a prospective database applying a systematic fistulomy technique in 101 patients requiring surgery for fistula in ano at LAC+USC Medical Center during a 15-month period. Data were collected for the reliability of primary crypt palpation, success of tract injection with peroxide/methylene blue, and the accuracy of Goodsall's rule. Time to healing, recurrence, and incontinence according to type of procedure were also recorded. Palpation of the primary crypt was possible in 93 per cent. Hydrogen peroxide/methylene blue injection successfully delineated the tract in 83 per cent. Goodsall's rule was correct in 81 per cent. Each fistula was categorized as intersphincteric (n = 72), transphincteric (n = 33), extrasphincteric (n = 1), or submucosal (n = 6). At a mean follow-up period of 44 weeks, 89.2 per cent of patients were cured. Reasons for recurrence included wound bridging (n = 6), misdiagnosis of the tract (n = 3), and two blind-ended fistulae (n = 2). Time to healing in weeks was (mean, range): simple fistulotomy (12, 3-21), seton (16, 4-28), Hanley procedure (28, 8-48). Patients with a marsupialized tract healed at an average of 6 weeks (range 4-8). Four (3.9%) patients reported postoperative incontinence (1 gas, 3 liquid, 0 solids).

Factors Associated with a Short (<2 Days) or Long (>10 Days) Length of Stay after Colectomy: A Multivariate Analysis of over 400 Patients.

A prospectively maintained database of 415 patients undergoing colectomy was evaluated. We performed a logistic regression analysis to identify factors associated with 1) length of stay (LOS) of 2 days or less and 2) LOS of 10 days or more. Investigated variables included demographics, American Society of Anesthesiology (ASA) score, diagnosis, operative procedure, approach and time, transfusion requirements, and occurrence of any complications. Factors associated with a LOS of two days or less included ASA [odds ratio (OR): 0.34, 95% confidence interval (CI): 0.208-0.576], use of transversus abdominis plane block (OR: 5.259, 95% CI: 2.825-9.791), and operative time (OR: 0.98, 95% CI: 0.974-0.986). Age >65 had an OR of 1.73, though this did not reach statistical significance. Factors associated with LOS >10 days included ASA (OR: 2.152, 95% CI: 1.245-3.721), anastomotic leak (OR: 2.163, 95% CI: 1.486-3.148), ileus (OR: 8.790, 95% CI: 4.501-17.165), and surgical site infection (OR: 5.846, 95% CI: 2.764-12.362). Cancer and transfusion status were associated but did not reach statistical significance. Although operative time was longer in left-sided resections, no differences in LOS were observed. In conclusion, numerous factors are associated with short or long LOS and may help stratify resource utilization after colectomy. Further study is needed to confirm our findings.

Anorectal anatomy.

A working knowledge of anorectal and pelvic anatomy is crucial for the understanding of normal function, pathogenesis and surgical treatment of anorectal diseases. In a field of unlimited details and varying definitions, our goal is to provide an overview of anatomic concepts relevant for the practical management of patients.

Use of high-dose-rate brachytherapy in the management of locally recurrent rectal cancer.

INTRODUCTION: Locally recurrent rectal cancer is associated with poor quality of life and has justified aggressive surgical and adjuvant approaches to control the disease. This study was designed to evaluate the use of fractionated perioperative high-dose-rate brachytherapy in association with wide surgical excision (debulking). Our hypothesis is that this combined therapy can help control locally recurrent rectal cancer. METHODS: Patients with biopsy-proven locally recurrent rectal cancer that could not be completely removed surgically were considered candidates for this procedure. All patients had abdominal exploration, aggressive tumor debulking, and placement of afterloading brachytherapy catheters. Patients underwent simulation on postoperative Day 3 and received 1,200 to 2,500 (mean, 1,888) cGy of fractionated high-dose-rate brachytherapy between postoperative Days 3 and 5. All patients had involvement of the lateral pelvic sidewall and/or the sacrum. RESULTS: Twenty-seven patients (18 males) aged 32 to 79 years underwent therapy. Follow-up ranged from 18 to 93 (mean, 50) months and was available in 27 patients. Ten patients (37 percent) were alive at the time of this report. Nine patients are without evidence of disease. Five patients (18 percent) died of non-cancer-related causes without evidence of recurrent disease. Five complications potentially related to treatment (3 abscesses, 2 fistulas) occurred in five patients. CONCLUSION: High-dose radiation brachytherapy delivers high-dose, highly controlled, focused radiation to specific sites of disease, thereby minimizing injury to normal tissues. The results in this series suggest increased local control, better palliation, and increased salvage of patients.