Benign Anorectal Disorder Management in Low-Resource Settings.

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

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.

Miscellaneous Perianal Afflictions.

This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis?

BACKGROUND: Laparoscopic sigmoidectomy for diverticulitis is widely accepted, using either endolinear staplers or traditional linear staplers under direct vision through the extraction site to transect the rectum. The aim of this study was to assess modifiable factors affecting perioperative morbidity after elective laparoscopic sigmoidectomy for diverticulitis. METHODS: Potential associations between perioperative morbidity and demographic, disease-related, and treatment-related factors were assessed on all consecutive patients included in a prospectively collected database undergoing elective laparoscopic sigmoidectomy for diverticulitis between 1992 and 2013. Rectal transection with a linear stapler under direct vision through the extraction site was considered compatible with laparoscopic technique. RESULTS: There were two deaths out of 1059 patients (0.19 %). Conversion rate was 13.1 %, overall morbidity 28 %, and anastomotic leak 3.7 %. Independent factors associated with morbidity in an intent-to-treat analysis were ASA 3 (OR 1.53, p = 0.006), conversion (OR 1.71, p = 0.015), and rectal transection without endolinear stapling (traditional linear stapler: OR 1.75, p = 0.003; surgical knife: OR 2.09, p = 0.002). The same factors along with complicated diverticulitis (OR 1.56, p = 0.013) were independently associated with overall morbidity among laparoscopically completed cases. BMI ≥ 35 (OR 2.3, p = 0.017), complicated diverticulitis (OR 2.37, p = 0.002), and rectal transection with a traditional linear stapler (OR 2.19, p = 0.018) were independently associated with abdomino-pelvic infections, both in an intent-to-treat analysis and among laparoscopically completed cases. The number of endolinear stapler firings was not associated with morbidity. CONCLUSIONS: Most factors associated with morbidity of laparoscopic sigmoidectomy for diverticulitis cannot be easily modified. With the limitation of a retrospective analysis, modifiable factors to minimize morbidity are laparoscopic completion and endolinear stapling.

Is it really small-bowel obstruction in patients with paradox after IPAA?

BACKGROUND: Diagnosing outlet obstruction after IPAA can be challenging because the etiology is multifactorial. OBJECTIVE: The aim of this study was to assess possible factors associated with outlet obstruction from paradoxical anal muscle contraction (paradox) after IPAA unrelated to strictures or structural abnormalities. DESIGN: This was a retrospective study from a prospectively maintained pouch database. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: All of the patients with paradox after ileal J-pouch-anal anastomosis verified by anal physiology were identified from our prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other anatomic abnormalities were excluded. MAIN OUTCOME MEASURES: Demographic, clinical, and perioperative factors were obtained, including previous abdominal operations, history of pouchitis, need for anal intubation, diagnosis of small-bowel obstruction, and radiologic findings at the time of paradox diagnosis. RESULTS: There were 40 patients (17 women) with an overall mean age of 39 years (range, 17-60 years) and a mean follow-up of 15 years (range, 1-28 years) after IPAA. Pathologic diagnoses at the time of ileal pouch creation were ulcerative colitis (n = 27), indeterminate colitis (n = 11), Crohn's disease, and familial adenomatous polyposis (1 case each). A total of 15 (37%) of 40 patients were diagnosed with small-bowel obstruction before their paradox diagnosis, 8 of whom underwent surgery, which revealed diffusely dilated small bowel and pouch without intraoperative identification of a transition point. The time from ileal pouch creation to paradox diagnosis was significantly longer in patients receiving a diagnosis of small-bowel obstruction than in the remaining paradox patients (7.2 vs 2.6 years; p < 0.001). LIMITATIONS: This study was limited by its nonrandomized retrospective nature. CONCLUSIONS: After an IPAA, patients with outlet obstruction from paradox can appear to have a small-bowel obstruction. A high incidence of suspicion is needed to make the correct diagnosis and avoid an unneeded laparotomy.

Twenty-year-old stapled pouches for ulcerative colitis without evidence of rectal cancer: implications for surveillance strategy?

BACKGROUND: The risk of anal transition zone dysplasia/cancer after stapled IPAA for ulcerative colitis might be cumulative over time. OBJECTIVE: The purpose of this work was to assess the long-term incidence and risk factors of anal transition zone dysplasia. DESIGN: This was a retrospective study from a prospectively maintained database. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Participants included those in our surveillance program of serial anal transition zone biopsies after stapled IPAA from 1986 to 1992. MAIN OUTCOME MEASURES: Anal transition zone dysplasia was the main measured outcome. RESULTS: Of 532 patients, 285 had 2 or more anal transition zone surveillance biopsies, including 73 with ≥20 years of regular follow-up. No adenocarcinoma was detected, and 15 patients died of unrelated causes after a median follow-up of 13.4 years (range, 2.9-19.5 years) without dysplasia. The estimated survival rates at 10, 15, and 20 years were 99.6% (95% CI, 96.9-99.9), 98.9% (95% CI, 95.7-99.7), and 92.6% (95% CI, 86.5-96.0). The estimated rates of anal transition zone dysplasia based on the 9 patients were 2.9% (95% CI, 1.5-5.7) and 3.4% (95% CI, 1.8-6.4) at 10 and 15 years. No new-onset dysplasia was identified beyond 125 months. Postoperative anal transition zone dysplasia was significantly associated with both preoperative and pathology findings of colorectal dysplasia (p < 0.001 for each) or cancer (p = 0.025 and p <0.001) and was managed expectantly or with mucosectomy (5 and 4 patients), depending on the number of positive biopsies and degree of dysplasia. Continued surveillance after detection of anal transition zone dysplasia showed no evidence of recurrent dysplasia during a median follow-up of 125 months (range, 9-256 months). LIMITATIONS: Approximately half of the eligible patients were excluded from the analysis because of insufficient follow-up. CONCLUSIONS: Long-term follow-up data corroborate the use of stapled IPAA for ulcerative colitis. Future studies should assess whether a less intensive surveillance strategy is safe 10 years after surgery.

Medical versus Surgical Patients with Clostridium difficile Infection: Is There Any Difference?

Severity of Clostridium difficile infection (CDI) varies from one patient to another. We aimed to test the hypothesis that surgical patients would suffer more severe CDIs than medical patients. Patients receiving in-hospital medical or surgical treatment for any underlying disease from 2007 to 2012, who developed CDI, were divided into two groups: "Medical group" and "Surgical group." Demographics, disease characteristics, and outcomes including mortality and recurrence were compared. Of 3231 patients with CDI evaluated, 1984 (61.4%) and 1247 (38.6%) were medical and surgical patients, respectively. Surgical patients had more severe CDIs than medical. However, the long-term effects of CDI were worse in medical patients, with more and quicker deaths. Recurrence was comparable between groups. Surgical patients were more frequently male, older, and obese; had higher white blood cells but lower levels of hemoglobin, hematocrit, and prealbumin; and had a higher rate of severe CDI. Conversely, medical patients had fewer in-hospital days, CDI appeared earlier, and had greater 30-day mortality and total number of deaths, with death after CDI occurring earlier. Although surgical patients tend to have a stormier clinical course related to CDI, overall they do better than medical patients. Future studies focusing on modifiable risk factors for each group are needed.