Layered surgical repair of traumatic cloacal deformities: technical details and functional outcomes.

BACKGROUND: Traumatic cloaca due to severe obstetric injury is a disabling condition that results in debilitating fecal incontinence, sexual dysfunction, and psychosocial distress for the patients, and poses a complex and challenging clinical situation for the surgeon. The aim of this study is to describe our technique and functional outcomes for the surgical repair of traumatic cloacal deformities. METHODS: Between 2000 and 2010, four women with traumatic cloacal deformities related to obstetric injury underwent repair by a single surgeon. In all patients, a systematic layered repair of the anovaginal structures was performed, including internal and external sphincteroplasties, without the implementation of tissue flaps or fecal diversion. Anorectal function before and after surgery as well as wound healing was evaluated. The patients presented 4.8 years after the obstetric injury. Mean preoperative Fecal Incontinence Severity Index was 34. All patients had complete disruption of the perineum, anal canal, distal vagina, and rectum, with a mean external sphincter defect of 151 degrees. RESULTS: Postoperatively, there were no wound-related complications and complete healing occurred by the fourth week. Median long-term follow-up was 4.5 years. At long-term follow-up, mean postoperative Fecal Incontinence Severity Index score was zero and all patients reported complete absence of dyspareunia. CONCLUSIONS: A layered surgical repair of cloacal deformities after severe obstetrical injury is associated with excellent functional outcomes and cosmetic results. The need for fecal diversion or complex surgical flaps for wound closure is obviated in this small series.

T-level downstaging and complete pathologic response after preoperative chemoradiation for advanced rectal cancer result in decreased recurrence and improved disease-free survival.

PURPOSE: Preoperative chemoradiation therapy is used widely in the treatment of rectal cancer. The predictive value of response to neoadjuvant remains uncertain. We retrospectively evaluated the impact of response to preoperative and, specifically, of T-level downstaging, nodal downstaging, and complete pathologic response after chemoradiation therapy on oncologic outcome of patients with locally advanced rectal cancer. METHODS: There were 88 patients with ultrasound Stage T3/T4 midrectal (n = 37) and low rectal (n = 51) cancers (63 males; mean age 62.6 years). All patients were treated by preoperative 5-fluorouracil-based chemotherapy and pelvic radiation followed by surgical resection in six weeks or longer (56 sphincter-preserving resections). RESULTS: T-level downstaging after neoadjuvant treatment was demonstrated in 36 (41 percent) of 88 patients, and complete pathologic response was observed in 16 (18 percent) of the 88. Of the 42 patients with ultrasound-positive nodes, 27 had no evidence of nodal involvement on pathologic evaluation (64 percent). The overall response rate (T-level downstaging or nodal downstaging) was 51 percent. At a median follow-up of 33 months, 86.4 percent of patients were alive. The overall recurrence rate was 10.2 percent (three patients had local and six had metastatic recurrences). Patients with T-level downstaging and complete pathologic response were characterized by significantly better disease-free survival (P = 0.03, P = 0.04) and better overall survival (P = 0.07, P = 0.08), according to Wilcoxon's test comparing Kaplan-Meier survival curves. None of the patients with complete pathologic response developed recurrence or died during the follow-up period. CONCLUSION: T-level downstaging and complete pathologic response after preoperative chemoradiation therapy followed by definitive surgical resection for advanced rectal cancer resulted in decreased recurrence and improved disease-free survival. Advanced rectal cancers that undergo T-level downstaging and complete pathologic response after chemoradiation therapy may represent subgroups that are characterized by better biologic behavior.

Abdominal compartment syndrome with massive lower-extremity edema caused by colonic obstruction and distention.

Abdominal compartment syndrome is a well-described condition in which increased intra-abdominal pressure causes various physiologic derangements with adverse effects on cardiac, pulmonary, and renal function. A patient presented with radiation-induced distal colonic obstruction, abdominal distention, and severe bilateral leg edema. We performed a diverting transverse loop colostomy as treatment for her obstruction. This resulted in massive, spontaneous diuresis with complete resolution of her lower-limb edema. Abdominal compartment syndrome due to colonic obstruction can contribute to the development of lower-extremity edema. Colon decompression with reduction of intra-abdominal pressure can lead to resolution of edema in this situation.

Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty.

PURPOSE: This study evaluated the effectiveness of combining advancement flap with sphincteroplasty in patients symptomatic with rectovaginal fistula and anal sphincter disruption. METHODS: Twenty patients with rectovaginal fistulas and anal sphincter disruptions after vaginal deliveries underwent combined rectal mucosal advancement flap and anal sphincteroplasty between July 1986 and July 1993. The mean age of the patients was 30 (range, 18-40) years and the mean duration of symptoms was 54.8 weeks (range, 7 weeks to 6 years). In addition to mucosal advancement flap repair, 13 patients underwent two-layer repair of anal sphincters (with reapproximation of the puborectalis in 8 of the patients); 6 patients underwent one-layer overlap repair of anal sphincters (with reapproximation of the puborectalis in 2 of the patients); and 1 patient underwent reapproximation of internal anal sphincter alone because squeeze pressures were adequate, as determined by anal manometry. RESULTS: Postoperatively, vaginal discharge of stool and flatus was eliminated entirely in all 20 patients. Perfect anal continence of stool and flatus was restored in 14 patients (70 percent). Incontinence was improved but not eliminated in six patients (4 incontinent to liquid stool and 2 to flatus), and two patients required perineal pads. Subjectively, 19 patients (95 percent) reported the result as excellent or good. There were no complications. CONCLUSION: The combination of mucosal advancement flap and anal sphincteroplasty is a safe and highly effective procedure for correcting rectovaginal fistula with sphincter disruption after obstetrical injuries.

Revised technique for retrieving small polyps from the colon and rectum after snare polypectomy.

Use of a nylon tissue biopsy bag at the suction port during snare colonoscopic polypectomy refines our previously reported technique in which we used a 4-inch x 4-inch gauze pad. The nylon tissue biopsy bag results in superior pathologic specimens, maintains simplicity of the technique, and is cost effective.

Intubation of the ileocecal valve made easy.

Intubation of the ileocecal valve and terminal ileoscopy is useful clinically, especially in conjunction with diagnostic colonoscopy in patients with suspected or established inflammatory bowel disease or lower gastrointestinal tract bleeding. We describe a simple method of successful intubation of the ileocecal valve to facilitate ileoscopy. This method also confirms successful completion of colonoscopy, because the ileocecal valve is the most relevant endoscopic landmark of the cecum.

Endorectal mucosal advancement flap: the preferred method for complex cryptoglandular fistula-in-ano.

Cryptoglandular fistula-in-ano is a common affliction that usually responds well to conventional surgical procedures such as fistulectomy, fistulotomy, and seton placement. These procedures, however, can be associated with varying degrees of fecal incontinence. Endorectal mucosal advancement flap has been advocated as an alternative procedure that avoids this problem. This study was undertaken to determine the risks and benefits associated with endorectal mucosal advancement flap in the treatment of complex fistula-in-ano. One hundred sixty-four patients underwent 167 endorectal mucosal advancement flap procedures for complex cryptoglandular fistula-in-ano between January 1982 and December 1990. There were 126 men and 38 women whose mean age was 42.1 years (range 20 to 79 years). The majority of the patients (70%) had complex fistulas (transsphincteric, suprasphincteric, or extrasphincteric). Fifteen patients (9%) had an intersphincteric fistula. All patients were available for short-term follow-up (6 weeks). Postoperative morbidity was minimal and included urinary retention in 13 patients (7.8%) and bleeding in one patient. Healing time averaged 6 weeks. Long-term follow-up, ranging from 19 to 135 months, was carried out in 61 patients. There were two recurrences (3.28%). Nine patients (15%) complained of varying degrees of fecal incontinence. Six patients complained of incontinence to flatus and three patients complained of incontinence to liquid stool. No patient was incontinent of solid stool. Sixty patients (98%) rated their functional result as excellent or good. Endorectal mucosal advancement flap is a safe and effective technique for the treatment of complex cryptoglandular fistula-in-ano. It can be performed with minimal morbidity, no mortality, an acceptable recurrence rate, and little alteration in anorectal continence.

Transanal endoscopic microsurgery. Initial registry results.

UNLABELLED: Transanal endoscopic microsurgery (TEM) was first used on a regular basis in the United States in 1990. Because there is a sole source of instrumentation, the surgeons who use this equipment are known to us. Thus, this earliest registry is a compilation of data based on most patients who underwent TEM in the United States from 1990 to 1994. METHOD: One hundred fifty-three cases were voluntarily registered by six surgeons. Pathology included 54 carcinomas, 82 adenomas, and 17 other entities. Most resections were full thickness. Fifty percent of cases were out of reach of standard instruments. Complication rate, hospital stay, and blood loss were recorded. Technical difficulties at time of surgery (9 percent), early complications (15 percent), and late complications (5 percent) have been tabulated. RESULTS: Recurrence rates for carcinoma were 10 percent for T1, 40 percent for T2, and 66 percent for T3 stages. Failures were treated by abdominoperineal resection or low anterior resection. Adenomas recurred in 11 percent, but these recurrences were small and easily treatable. CONCLUSION: TEM has a low complication rate. By carefully selecting small, superficial cancers and adenomas, TEM results in superior outcome over other approaches to the mid and upper rectum.

Colonoscopic bowel preparations--which one? A blinded, prospective, randomized trial.

UNLABELLED: For the past decade peroral, orthograde, polyethylene glycol-electrolyte lavage solutions (PEG-ELS) have been the preferred bowel-cleansing regimens before diagnostic and therapeutic procedures on the colon and rectum. The large volume and unpalatibility of these solutions may lead to troubling side effects and poor patient compliance. PURPOSE: This study was undertaken to determine which of various colon-cleansing methods before colonoscopy would provide greater patient acceptance while maintaining similar or improved effectiveness and safety. METHODS: Three hundred twenty-nine patients undergoing elective ambulatory colonoscopy were prospectively randomized to one of three bowel preparation regimens. Group 1 received 41 of PEG-ELS (n = 124). Group 2, in addition to PEG-ELS, received oral metoclopramide (n = 99). Group 3 received oral sodium phosphate (n = 106). All groups were evenly matched according to age and sex. RESULTS: Ninety-one percent of all patients completed the preparation received. Sixteen percent of patients suffered significant sleep loss with a bowel preparation. When comparing the three groups, there was no difference in the assessment of nausea, vomiting, abdominal cramps, anal irritation, or quality of the preparation. Compared with other preparations, oral sodium phosphate was better tolerated. More patients completed the preparation (P < or = 0.001). Fewer patients complained of abdominal fullness (P < or = 0.001). More patients were willing to repeat their preparation (P < or = 0.02). Also, sodium phosphate was found to be four times less expensive than either of the PEG-ELS preparations. CONCLUSION: All regimens were found to be equally effective. Abdominal symptoms and bowel preparation were not influenced by the addition of metoclopramide. The oral sodium phosphate preparation was less expensive, better tolerated, and more likely to be completed than either of the other preparations.

Transanal endoscopic microsurgery. Results of the initial ten cases.

Transanal endoscopic microsurgery (TEM) permits precise excision of favorable tumors from the mid and proximal rectum, thus avoiding transsacral and low anterior resection in select cases. Ten patients underwent TEM resection of rectal tumors by a single surgeon between April 1992 and August 1993. All patients first underwent endorectal ultrasound. Villous adenomas ranging from 3.2 to 4.5 cm in size (mean, 3.9 cm) in eight patients and T1 adenocarcinomas of 1.5 and 2.5 cm (mean, 2 cm) in two patients were excised. Resection was performed using the mucosectomy method in three and by full-thickness excision in seven patients. Distal extent of tumors ranged from 6 to 11 cm from the anal verge. The operative time in these initial ten cases ranged from 75 to 220 min (mean, 138 min). Estimated blood loss ranged from 0 to 550 cc (mean, 85 cc). Complications occurred in two patients (pseudomembranous colitis; fever of unknown origin). The mean length of hospital stay was 2.7 days. To date, one tumor has recurred, requiring an abdominoperineal resection. In no case was conversion to conventional method of resection necessary at the time of TEM resection. TEM is a safe and effective method for resecting favorable tumors in select cases.

Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach.

PURPOSE: We categorized the various types of post-obstetric injuries of the anorectum and vagina encountered in a five-year period. The operative procedures used to repair these injuries and the functional outcome after surgery were assessed. METHODS: Between 1986 and 1991, 52 patients were surgically treated for obstetric injuries of the anorectum and vagina; 48 patients were available for follow-up study. Four clinical injury types were identified: Type I, incontinent and sphincter (11 patients); Type II, rectovaginal fistula (16 patients); Type III, rectovaginal fistula and incontinent and sphincter (11 patients); and Type IV, cloaca-like defect (10 patients). The mean age of the patients was 30 years, the mean duration of symptoms before surgery was 13 months, and the mean follow-up period was 16 months. The major component of surgical repair for each injury type was: Type I, overlap repair of external anal sphincter; Type II, rectal mucosal advancement flap; Type III, overlap repair of external anal sphincter and rectal mucosal advancement flap; and Type IV, overlap repair of external anal sphincter, anterior levatorplasty, and anal and vaginal mucosal reconstruction. Fecal diversion was not performed in any patient. Specific questions were asked at the most recent follow-up assessment to determine results. RESULTS: Continence status postoperatively was classified as perfect, impaired, or poor; poor was defined as no improvement or worse. Postoperative continence (perfect impaired, or poor) was, respectively: Type I (11 patients), 64 percent, 36 percent, and 0 percent; Type II (16 patients), 56 percent, 0 percent, and 44 percent; Type III (11 patients), 64 percent, 36 percent, and 0 percent; and Type IV (10 patients), 90 percent, 10 percent, and 0 percent. Vaginal discharge of stool was eliminated in all patients with a rectovaginal fistula. Subjectively, 92 percent of the patients had excellent or good results. Complications included wound hematoma (n = 2), fecal impaction (n = 2), urinary retention (n = 1), and urinary tract infection (n = 1). CONCLUSION: Patients with Type II injuries had the worst results (P < 0.001). These patients should be evaluated for anal incontinence before surgery to assess the need for a concomitant sphincteroplasty.

Efficient technique for retrieving small polyps from the colon and rectum following snare polypectomy.

The use of a 4- x 4-inch gauze pad at the suction port during snare colonoscopic polypectomy facilitates the retrieval of polyps. This technique is a simple, rapid, and cost-effective method of retrieving small polyps for pathologic evaluation.

Squamous-cell carcinoma of the anal canal: management with combined chemo-radiation therapy.

Twenty patients with squamous-cell carcinoma of the anal canal received combined chemo-radiation therapy as their primary treatment. There were 18 women and two men with a mean age of 63 years (range, 34-91 years). The mean follow-up was 34 months (range, 6-62 months). Anal margin cancers and adenocarcinomas were excluded. Fourteen of 20 patients treated had a complete response. There were six local failures: three with residual disease at the end of treatment and three with recurrent disease at a later date. Of the three with residual disease, one underwent abdominoperineal resection and two received salvage therapy (one with chemo-radiation and one with radiation alone). All three patients with recurrent disease were treated with abdominoperineal resection. All six were disease free at the end of the study. Of the 14 patients with complete local response, one presented with liver metastases 19 months later. Sixteen patients (80 percent) were alive at the end of the study, and 19 patients (95 percent) had no evidence of disease. These data add support for salvage therapy in the treatment of patients with residual disease following initial chemo-radiation therapy. Salvage options for patients with squamous-cell carcinoma of the anus who fail the Nigro protocol will be discussed.

Preoperative versus postoperative adjuvant radiotherapy for surgically curable carcinoma of the rectum and distal sigmoid colon.

From January 1979 to October 1986, 86 patients with surgically resectable adenocarcinoma of the rectum or rectosigmoid were treated with adjuvant radiotherapy consisting of preoperative 2,400 cGy (22 patients), preoperative 4,000 cGy (14 patients), "sandwich" technique (27 patients), and postoperative irradiation (23 patients). Average follow-up was 42.9 months. The local recurrence rate was 4.5%, 9.1%, 7.4%, and 34.8%, respectively. The distant metastasis rate was 18.2%, 18.2%, 7.4%, and 30.4%, respectively. Preoperative radiotherapy with adequate surgical resection appears more effective in reducing the incidence of local recurrence.

A new silicone-prosthesis in the modified Thiersch operation.

Experience with a new silicone prosthesis in the modified Thiersch operation for rectal procidentia in 16 extremely poor-risk patients is presented. The technique of implantation, structural details of the prosthesis, and the clinical results are described. The use of a new silicone prosthesis in the modified Thiersch procedure is a viable alternative in this group of patients. Surgical technique is a primary determining factor in preventing complications.

Urecholine prophylaxis for urinary retention in anorectal surgery.

A randomized prospective trial with 108 patients undergoing anorectal surgery was conducted comparing the use of Urecholine orally or subcutaneously to no treatment controls. There was no difference in postoperative urinary retention rates and caudal or general anesthesia, nor was there an earlier postoperative bowel movement with Urecholine. The volume of intravenous fluids significantly affected retention rates.