Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Anorectal cancer following topical formalin application for haemorrhagic radiation proctitis

OBJECTIVE

Topical formalin has been used as an effective treatment for haemorrhagic radiation proctitis. In the course of reviewing our experience with this modality, we identified two patients who developed anorectal cancer during the follow-up period.

METHOD

From 2001 to 2005, 49 patients who received pelvic radiation for treatment of prostate, rectal or endometrial cancer subsequently developed haemorrhagic radiation proctitis. Four percent formalin was applied in the office setting under direct visualization with a rigid proctoscope and without sedation. Response to treatment was then reviewed.

RESULTS

Seventy-eight per cent of patients reported a complete response to formalin application. Only 14% were refractory to formalin treatment. Two patients subsequently presented with anorectal cancer.

CONCLUSION

Topical formalin application in the outpatient setting appears to be an effective first-line treatment for haemorrhagic radiation proctitis. We report the first cases of anorectal cancer which developed subsequent to formalin application. Pelvic irradiation is known to increase the risk of developing a second malignancy, therefore it is impossible to determine what, if any, role formalin application played in the development of the second malignancies.

Colorectal cancer in familial adenomatous polyposis

PURPOSE

This study was performed to determine the relationship among surgical treatment, colorectal cancer, and outcome in patients with familial adenomatous polyposis (FAP).

METHODS

Records of 115 patients with FAP who underwent surgery at The Mount Sinai Medical Center between 1947 and 1994 were retrospectively reviewed. Patients without cancer were compared with those with colorectal cancer at initial surgery and with patients who developed rectal cancer following colectomy.

RESULTS

Thirty-one patients (27 percent) had colorectal cancer at the time of initial surgery (colon = 24; rectal = 7). Another 11 patients (26 percent) developed rectal cancer after colectomy with ileorectal anastomosis (IRA). Mean age of patients with colorectal cancer at initial surgery was significantly higher than those without cancer (P < 0.01). Patients who developed rectal cancer after IRA were significantly older than patients with colorectal cancer at initial surgery (P < 0.01). All patients with rectal cancer after IRA had advanced disease with either nodal or distant metastases at the time of diagnosis.

CONCLUSIONS

Colorectal cancer remains a major problem in the treatment of patients with FAP. Nearly one-fourth of these patients have colorectal cancer at initial operation, and one-fourth of patients with IRA develop rectal cancer after a mean follow-up of 13 years. Patients with rectal cancer following IRA are more likely to have advanced tumors than patients with colorectal cancer at initial operation. The high incidence and late stage of rectal cancer detected while under surveillance after IRA supports excision of the entire colorectal mucosa as the treatment of choice for most patients with FAP.

Anal fissure. 20-year experience

PURPOSE

This study was designed to review a 20-year experience of the treatment of patients with anal fissure to identify possible etiologic factors and to explore effective preventative measures and the ideal treatment for this disease.

METHODS

From January 1972 to December 1991, 1,391 patients (700 males, 691 females; average age, 39 years) with chronic symptomatic anal fissures underwent surgical treatment using either open or closed techniques. The following procedures were performed: 1) internal sphincterotomy for 1,313 idiopathic fissures; 2) C-anoplasty for 36 cases of anal stricture; 3) debridement and sphincterotomy for 25 patients with postsurgical nonhealing wounds; 4) bilateral excision of the protruding internal sphincter for 17 patients with "subluxation." Acute superficial anal fissures were treated conservatively, with emphasis on anal hygiene.

RESULTS

Acute superficial and fissures responded well to conservative management. Over 95 percent of patients with chronic anal fissures treated by surgery had satisfactory relief of symptoms. Early complications included urinary retention (1.4 percent), bleeding (1.1 percent), and abscess and fistula formation (0.7 percent). Late complications manifested as flatus and liquid incontinence (1.5 percent), delayed wound healing (1.4 percent), recurrence of fissures (1.3 percent), and symptomatic itching and burning (1.1 percent). The complication rate was higher in the group that underwent closed sphincterotomy than in the group treated by open techniques.

CONCLUSIONS

Proper and hygiene is important in both prevention and initial conservative management of symptomatic anal fissures. For chronic intractable cases, open lateral internal sphincterotomy is strongly recommended. C-anoplasty should be done when strictures are present. Excision of the protruding internal sphincter is recommended in patients who present with an excessively elongated, tight anal canal with a partially protruding internal sphincter.

Lasers in anorectal surgery

Laser technology has been applied widely in the treatment of hemorrhoids, condylomas, and anorectal neoplasms. It is claimed by its proponents to result in less pain, improved healing, and more rapid recovery as compared with conventional surgery. Laser therapy, however, is expensive and potentially dangerous, and advantages generally have not been substantiated by controlled clinical trials. The possible benefits and potential risks of laser treatment of anorectal disorders are examined.

Surgical treatment of tumors of the distal rectum with sphincter preservation

One hundred one patients with villous adenoma or invasive carcinoma of the distal rectum treated with local excision or coloanal anastomosis were studied. Twenty-three (45%) of the 51 patients with villous adenomas had transanal excision, another 23 (45%) had a posterior proctotomy, and five (10%) had a coloanal anastomosis. Only two patients with a villous adenoma developed a recurrence requiring repeat local excision. Fifteen (30%) of the 50 patients with invasive cancer were treated by transanal excision. All had tumors confined to the submucosa or superficial muscularis. Eighteen (85%) of 21 patients having posterior proctotomy also had tumors with similar depth of invasion. Six (43%) of the 14 patients having coloanal anastomosis had Dukes' B tumors, six (43%) were Dukes' C, and another two (14%) underwent palliative resection. The overall actuarial 5-year survival was 77%. Only four patients treated by transanal excision or posterior proctotomy died of metastatic disease. In the coloanal group, two of 12 patients undergoing curative resection died of recurrent cancer, and another has a pelvic recurrence. Villous adenomas of the distal rectum and selected carcinomas may be treated with local excision and coloanal anastomosis with preservation of sphincter function with good results.

Toxic shock syndrome after pilonidal cystectomy. Report of a case

Toxic shock syndrome is an uncommon disease associated with staphylococcal infections. Although most frequently reported in menstruating women and associated with tampon use, toxic shock syndrome has been described following many types of surgical procedures. In this report we describe a case of toxic shock syndrome occurring in a previously healthy young man after elective surgery for a pilonidal cyst.

Anastomosis to the rectum. Operative experience

Four hundred sixty-six consecutive procedures involving anastomosis to the rectum were performed between March 1969 and December 1982. Three hundred ninety-six (85 percent) were stapled anastomoses and 70 (15 percent) were hand-sutured anastomoses. The stapled anastomoses were constructed using the GIA or EEA instrument, some of the latter utilizing a pull-through technique. The hand-sutured anastomoses were constructed in the pelvic space, or externally as a staged pull-through procedure. A diverting stoma was constructed in all 14 staged pull-through procedures, in 47 of 56 (84 percent) conventional hand-sutured anastomoses, and in 38 of 396 (10 percent) stapled anastomoses. While the majority of very low anastomoses (0 to 5 cm from the dentate line) were stapled, 13 conventional hand-sutured anastomoses and all 14 of the staged pull-through procedures were constructed at this level. One patient (0.2 percent) died as the result of an anastomotic complication. Twelve patients (2.5 percent) had anastomotic complications requiring reoperation. The reoperation rate for stapled anastomoses was six of 396 (1.5 percent). For hand-sutured anastomoses, the reoperation rate was six of 70 (8.6 percent). The results show that, for anastomosis to the rectum, stapling instruments are at least as good as hand-suturing. Both stapling techniques and hand-suturing techniques provide the surgeon the capacity to construct safely very low anastomoses. A temporary, diverting stoma is required much less frequently with stapled than with hand-sutured anastomoses. The need for a permanent colostomy should be determined by the stage and level of disease, the systemic health of the patient, and the patient's anatomy, rather than by the selection of anastomotic technique.

Monooctanoin dissolution of retained biliary stones in high risk patients

Monooctanoin, a cholesterol solvent, was infused into the biliary tracts of six high risk patients, in an attempt to dissolve retained stones. The infusion rate was constant, 5-10 ml/h. The mean age of the patients was 76 years. Associated medical conditions were primarily cardiac in nature. Duration of infusion averaged 6 days. In two patients, the stones were completely dissolved. One patient was reoperated despite the stones appearing smaller after 6 days of infusion. At surgery, no stones were found. Two patients in whom dissolution was unsuccessful underwent reoperation. In both, retrieved stones were composed of less than 5% cholesterol. Five of the six patients experienced at least one episode of mild abdominal pain and vomiting. None developed cholangitis, pancreatitis, or significant biochemical abnormalities. Two of the three who underwent reoperation tolerated it without difficulty. While mechanical extraction, when feasible, is still the treatment of choice for retained biliary stones, chemical dissolution should be attempted before undertaking reoperation.