Fissurectomy Combined with High-Dose Botulinum Toxin Is a Safe and Effective Treatment for Chronic Anal Fissure and a Promising Alternative to Surgical Sphincterotomy.

BACKGROUND: There is paucity of data on the long-term outcome of the combination of fissurectomy and botulinum toxin A injection for the management of chronic anal fissure. OBJECTIVES: The aim of this study is to assess the safety, efficacy, and long-term outcome of the combination of fissurectomy and botulinum toxin A injection. DESIGN: This is a nonrandomized prospective cohort study. SETTINGS: This study was conducted at a district general hospital in the United Kingdom. PATIENTS: The cohort included all patients treated with fissurectomy and botulinum toxin A for chronic anal fissure between September 2008 and March 2012. INTERVENTION: The patients were treated with a combination of fissurectomy and botulinum toxin A injection. MAIN OUTCOME MEASURES: Symptomatic relief, fissure healing, complications, recurrence, and the need for further surgical intervention. RESULTS: One hundred and two patients received fissurectomy and botulinum toxin A injection for chronic anal fissure. At 12-week follow-up, 68 patients had resolution of symptoms and complete healing of chronic anal fissure, 29 patients had improvement of symptoms but incomplete healing and had further topical or botulinum toxin A treatment with subsequent complete healing. Ninety-five patients (93%) reported no postoperative complications. Seven patients reported a degree of incontinence in the immediate postoperative period. All reported normal continence at12-week follow-up. No local complications were observed or reported. At the mean follow-up of 33 months, there was no evidence of recurrence. Twelve-month follow-up was conducted via telephone interview only. LIMITATIONS: This study is nonrandomized and did not examine the dose response of Botulinum Toxin A. CONCLUSIONS: Fissurectomy combined with high-dose botulinum toxin A is a safe, effective, and durable option for the management of chronic anal fissure and a promising alternative to surgical sphincterotomy.

Laparoscopic transabdominal preperitoneal repair of spigelian hernia-closure of the fascial defect is not necessary.

INTRODUCTION: Spigelian hernia (SH) is rare and is traditionally repaired using an open technique. There has been an increasing popularity of laparoscopic methods, with transabdominal preperitoneal (TAPP) repair being one of the popular techniques. Currently, most surgeons using the TAPP technique close the fascial defect prior to mesh placement. Here we report our experience with a TAPP repair that deliberately excludes approximation of the fascial defect. SUBJECTS AND METHODS: Prospective data were collected on consecutive patients undergoing elective SH repair under the care of a single surgeon between 2001 and 2012. Diagnosis was confirmed preoperatively using ultrasonography or computerized tomography. A laparoscopic TAPP repair was used without closing the defect. Following discharge all patients were followed up at 3 and 12 months. The clinical records were reviewed at the time this article was written. The technique, epidemiological characteristics, operative findings, hospital stay, morbidity, and follow-up are presented. RESULTS: Twenty-six patients (16 males) with a median age of 63 years were operated on. The follow-up period ranged between 6 months and 11 years (median, 4 years). Hernia defect size ranged from 2 to 10 cm. Mean operating time for unilateral defects was 45 minutes; that for bilateral defects was 70 minutes. Twenty-two patients were discharged on the same day. There were no postoperative complications or recurrences. CONCLUSIONS: Laparoscopic TAPP repair of SH without closing the defect is safe, effective, and durable. There is no additional benefit from routine closure of the fascial defect. On the contrary, there may be potential advantages in leaving the defect unopposed.

A giant colonic diverticulum presenting as a 'phantom mass': a case report.

INTRODUCTION: Diverticulosis coli is the most common disease of the colon in Western countries. Giant colonic diverticulum, defined as a colonic diverticulum measuring 4 cm in size or larger, represents an unusual manifestation of this common clinical entity. CASE PRESENTATION: A 68-year-old Caucasian British woman with a history of intermittent lower abdominal mass, leg swelling and focal neurological symptoms underwent extensive non-diagnostic investigations over a significant period under a number of disciplines. The reason for a diagnosis being elusive in part related to the fact that the mass was never found on clinical and ultrasound examination. As a result, the patient's validity was questioned. Ultimately, this 'phantom-mass' was diagnosed as a giant colonic diverticulum causing intermittent compression of the iliac vein and obturator nerve. CONCLUSION: Intermittent compression of the iliac vein and the obturator nerve by a colonic diverticulum has not previously been reported. A giant colonic diverticulum presenting as an intermittent mass is very rare. This case also illustrates two factors. First, the patient is often right. Second, the optimal mode of investigation for any proven or described abdominal mass with referred symptoms is cross-sectional imaging, typically a computed tomography scan, irrespective whether the mass or symptoms are constant or intermittent.

Aortoduodenal fistula and streptococcal myonecrosis.

Pyomyositis is a rare primary bacterial infection of the skeletal muscles. Pyomyonecrosis is the most severe manifestation of this disease and is associated with a potentially devastating outcome. Patients with peripheral vascular disease presenting with pyomyositis may be difficult to distinguish from those with critical ischemia or synthetic graft sepsis. This article reports on a patient with aortobifemoral bypass graft and severe vitamin B(12) deficiency who developed pyomyonecrosis and aortoduodenal fistula. This article highlights the etiologic dilemma, diagnostic difficulties, and management challenges inherent in such cases. Pitfalls in our management of this patient are discussed.

Short-term and long-term outcomes of the cleft lift procedure in the management of nonacute pilonidal disorders.

PURPOSE: We report the results of the cleft lift procedure in the management of nonacute pilonidal sinus disorders. METHODS: Seventy consecutive patients who underwent a cleft lift for nonacute pilonidal sinus were evaluated prospectively. Responses to a postal questionnaire were analyzed for long-term outcome. RESULTS: All patients who fulfilled the criteria for day-case were operated on as such. Sixty-six patients achieved complete wound healing within six weeks. Delayed wound healing occurred in three patients and nonhealing occurred in one. Fourteen patients had one or more complications: wound breakdown, superficial (n = 7) and deep (n = 1); wound infection (n = 5); wound seroma (n = 4); and early recurrence (n = 1). The median time off work and to return to normal activities was two and four weeks, respectively (range, 0.5-12). Forty-seven patients completed the questionnaire at a median follow-up of 24 months: five patients reported minimal tenderness in the sacral region; none reported recurrence of pilonidal symptoms; and all were satisfied. CONCLUSIONS: The cleft lift procedure is easy to perform as a day-case procedure. It is associated with high rates of primary healing, durable low recurrence rates, and early functional recovery. This technique may be the procedure of choice in the surgical management of nonacute pilonidal disorders.

Massive hemoperitoneum caused by rupture of an aneurysm of the marginal artery of Drummond.

Aneurysms of visceral arteries are uncommon and their rupture is rare. We report a case of an aneurysm of the marginal artery of Drummond, which was complicated by rupture leading to massive hemoperitoneum. A selective superior mesenteric arteriogram suggested the possibility of segmental arterial mediolysis (SAM) as a possible etiology and this was confirmed by histological examination. This is the first report of symptomatic SAM of the marginal artery of Drummond to date. This case demonstrates that the marginal artery of Drummond should be considered during the angiographic explorations for the source of hemoperitoneum. Management options are discussed.

Spontaneous regression of colorectal cancer: a review of cases from 1900 to 2005.

INTRODUCTION: Spontaneous regression of cancer is an exceptional but well-documented biological event. Further understanding of this phenomenon and harnessing of the mechanisms involved will have significant preventative and therapeutic implications. DISCUSSION: In this review, the literature of spontaneous regression of colon or rectal cancer is reviewed from 1965 to 2005 to update reviews by Everson et al., Boyd and Challis et al. By adding to these, the author reports the entire series of colorectal cancer, which underwent documented spontaneous regression from 1900 to 2005. The demographic and pathologic characteristics, the details of regression and the outcome of reported cases are presented and discussed. Special emphasis is placed on identifying possible causes hypothesized by authors for occurrence of regression. Possible mechanisms operating to affect these regressions are also discussed.

Nicorandil-associated para-stomal ulceration: Case series.

Nicorandil is a vasodilator used to control severe angina. It has been associated with oral and anal ulceration that resolves upon withdrawal of the drug. We report a series of four patients, all of whom were receiving nicorandil therapy and developed nonspecific para-stomal ulcerations of similar clinical and histological appearance. All ulcers healed on withdrawal of nicorandil with no relapse. To the best of our knowledge, nicorandil-associated para-stomal ulcers have not been reported before. It is imperative to be aware of this association to prevent the persistence of these extremely painful ulcerations, and to avoid unnecessary and inappropriate interventions with substantial morbidity in a group of high-risk patients.

Laparoscopy-associated portal vein thrombosis: description of an evolving clinical syndrome.

Several cases of portal vein thrombosis following laparoscopic procedures have been reported over the past few years. To date, no formal description of this phenomenon has been provided. In this paper, we summarize and analyze the features of the 4 reported cases to date as well as a fifth case encountered at our institution. The probable causes of this complication include changes in coagulation status, splanchnic hemodynamics, and portal venous blood flow, all of which may be related to carbon dioxide absorption and increased intra-abdominal pressure. The recognition of this phenomenon and its management are discussed. A review of the relevant literature is provided.

Spontaneous regression of peritoneal carcinomatosis from a rectal cancer.

Spontaneous regression of adult solid tumours is rare. Here, we present the case of a 51-year-old man who underwent a curative resection for an adenocarcinoma of the rectum in 1989. He remained well until 12 months after surgery when he developed a large-fixed mass proximal to the anastomosis, which was treated with radiotherapy but did not respond. Shortly after, he presented with intestinal obstruction caused by extensive intraperitoneal metastases. At laparotomy, a palliative entero-enterostomy and ileostomy were performed. Biopsies from the peritoneal lesions showed features typical of metastatic adenocarcinoma. The patient did not receive any additional therapy. However, his condition continued to improve; he remains disease free and well at present (May 2005). A review of the literature revealed two cases of spontaneous regression of peritoneal carcinomatosis secondary to a rectal cancer; we report the third case and discuss some of the reasons potentially responsible for the regression.

Ileitis in ulcerative colitis: is it a backwash?

PURPOSE: This study aims to determine the incidence, demography, pathologic nature, and clinical significance of ileitis in ulcerative colitis patients who underwent restorative proctocolectomy. METHODS: A prospectively collected pouch database and the case notes of 100 consecutive patients who underwent restorative proctocolectomy for ulcerative colitis, under the care of a single surgeon, between 1988 and 2003 were reviewed. The original proctocolectomy specimens and pouch biopsies were reexamined and regraded blind, using the current diagnostic criteria. Patients were divided into two groups, those who had ileitis and those who had not. The demographic, clinical, and pathologic characteristics and the incidence of pouchitis of both groups were compared. RESULTS: Twenty-two patients had ileitis (22 percent). Compared with those with noninflamed ileum, patients with ileitis had a significantly shorter disease duration (P < 0.005), many of them presented or progressed to a fulminant state requiring acute surgical intervention (P < 0.01), had strong association with pancolitis and primary sclerosing cholangitis (P < 0.001), and had a higher incidence of subsequent development of pouchitis (P < 0.001). There was no correlation between the presence of ileitis and colitis severity. CONCLUSIONS: Ileitis in ulcerative colitis is not rare and does influence the prognosis, and the term "backw ash" is a misnomer. Ulcerative colitis with ileitis represents a distinct disease-specific subset of patients. Its true incidence and clinical significance can be determined only if detailed microscopic characterization of the terminal ileum is performed routinely in every patient with ulcerative colitis and the clinical outcome of these patients is audited prospectively.

Implications of pouchitis on the functional results following stapled restorative proctocolectomy.

PURPOSE: Pouchitis is the most frequent long-term complication of restorative proctocolectomy; its long-term consequences are inadequately described. This prospective study evaluates the effect of pouchitis on the functional results, general health perception, and patient satisfaction. METHODS: A total of 100 consecutive patients who underwent stapled restorative proctocolectomy for ulcerative colitis were divided into three groups: no pouchitis, acute pouch-itis and chronic pouchitis. Functional results, general health perception, and satisfaction of each group at the latest review were compared only when patients were not symptomatic of active pouchitis. RESULTS: Pouchitis occurred in 33 patients (17 acute and 16 chronic). There were no significant differences in the long-term functional results between the no pouchitis and acute pouchitis groups. Patients who experienced chronic pouchitis had a significant increase in bowel movements, looseness of stools, urgency, nocturnal seepage, perianal excoriation, and dietary restrictions (P < 0.05). They also had a worse perception of their general health (P < 0.05). Previous chronic pouchitis had no effect on continence, daytime soilage, or gas-feces discrimination. Most patients were satisfied, despite pouchitis, and would recommend the operation to someone else with ulcerative colitis. CONCLUSIONS: Acute pouchitis is easily treated and results in minimal functional consequences. Even in the absence of clinically active pouchitis, patients who had suffered from chronic pouchitis had poorer functional results and general health perception. This may overshadow the benefits of restorative proctocolectomy. This finding suggests that acute and chronic pouchitis are distinct disease entities and chronic pouchitis may represent a persistent condition that displays episodic symptomatic exacerbation.

Lymphoscintigraphic demonstration of chylous leak after axillary lymph node dissection.

Chyle leak is a potentially serious complication resulting from violation of the thoracic duct, right lymphatic duct, or one of their terminal branches. It may impair nutrition and immunity, compromise and delay wound healing, prolong hospitalization, and delay adjuvant therapy. After surgery for breast carcinoma, this is a rare occurrence. Here, the author describes a novel application of lymphoscintigraphy showing thoracic duct injury after a wide excision and axillary clearance.

Pouchitis-associated pyoderma gangrenosum following restorative proctocolectomy for ulcerative colitis.

A 43-year-old female with ulcerative colitis treated by proctocolectomy and ileal pouch--anal anastomosis developed acute pouchitis. Although no extra-intestinal manifestations were present before the surgical procedure, pyoderma gangrenosum developed concomitantly with the appearance of acute pouchitis. Both conditions completely resolved with oral metronidazole only. This is the first report of acute pouchitis-related pyoderma gangrenosum. This association suggests that pouchitis may represent a recurrent ulcerative colitis-like syndrome within the novel environment of the pouch.