Horseshoe Fistulae in the Age of LIFT.

BACKGROUND: Horseshoe fistula is a challenging benign anorectal condition to treat. The aim of this study was to assess the utilization and success of different definitive fistula repair techniques in the treatment of horseshoe fistula. METHODS: This was a retrospective case series which included all patients who were treated for horseshoe fistula from 2006 to 2019 at a single, tertiary care center and whom had at least one follow-up visit. Patients were excluded if < 18 years of age or carried a diagnosis of Crohn's disease. Patients were assessed for fistula recurrence and incontinence. RESULTS: Sixty-eight patients were identified. On average, they were 47 years old, 63% male, and 18% current smokers. Seventy-nine percent required seton during their treatment course. Of the 8 first attempts at fistula repair, the types of repair included flap (15%), LIFT (35%), fistulotomy (31%), plug (12%), and fistulotomy and immediate reconstruction (1%). Recurrence for these procedures was as follows: flap 30%, LIFT 21%, fistulotomy 14%, plug 88%, and fistulotomy and immediate reconstruction 0%. Twelve patients who recurred underwent 17 additional procedures to attempt to cure their fistula. Overall, of those who underwent any attempt at definitive repair, 82% of patients were cured of their fistula, 12% had a chronic seton, and 6% had a chronic fistula. Thirteen percent of those who were cured had incontinence. The mean follow-up time was 1.1 years. Patients required a median of 3 procedures (range 1-11). CONCLUSION: Horseshoe fistula remains a complex anorectal condition. Successful repair can be performed in > 80% of patients. However, repair can often require multiple surgical procedures.

How to Get Ahead: Early-Career Colorectal Surgeons Reflect on Their First Few Years in Practice.

OBJECTIVE: To identify strategies and barriers to career progression in early-career colorectal surgeons. DESIGN: Qualitative research study performed via semi-structured interviews with early-career, board-certified colon, and rectal surgeons. Responses were analyzed, coded, and categorized to understand strategies towards career progression, perceived barriers to career progression, beliefs about case mix, and referral patterns. SETTING: Interviews conducted in person and via telephone across the United States and Canada. PARTICIPANTS: Early-career board-certified colorectal surgeons RESULTS: Twenty-two board-certified colorectal surgeons currently employed in 14 states and 1 foreign country were interviewed. Fourty-five percent were female. Their current practice environment was described as academic (77%), private practice (18%), or military (5%). Seventy-seven percent of surgeons were satisfied with their career progression. Seventy-two percent were satisfied with the case volume. Seventy-two percent were satisfied with their case mix. When asked about strategies for career progression, surgeons made 77 comments focused on three main themes: optimization of their job search, optimization of relationships while on the job, and efforts to augment individual achievement. When asked about barriers to career advancement, surgeons most frequently commented on a lack of time and a lack of mentors. When asked about case mix, 63% of surgeons felt that they had no control over it. They were evenly divided between believing that a broad case mix or a niche specialized case mix was more instrumental for career progression. CONCLUSIONS: Early-career colorectal surgeons were mostly satisfied with their career progression, volume, and case mix. In discussing their careers, many have developed a number of strategies focused on growth as an individual as well as relationship building. They also identified a number of barriers including lack of time and lack of mentorship. Early-career surgeons may be able to utilize these strategies and anticipate barriers prior to starting their first job, leading to greater likelihood of career satisfaction.