Pelvic Fistulas in Coloproctology

Comparison between three therapeutic modalities for non-complicated pilonidal sinus disease.
Mohamed HA, Kadry I, Adly S
Surgeon. 2005 Apr;3(2):73-7.

OBJECTIVE: To evaluate the outcome of each of the three methods used to treat pilonidal sinus disease. STUDY DESIGN: A prospective blind randomised study. MATERIALS AND METHODS: Between April 2000 and February 2003, 83 patients (68 male and 15 female), aged between 19 and 31 years (mean 26.6), scheduled for elective operations for pilonidal sinus disease. Patients were randomly assigned to receive one of three excisional surgical procedures. Group A consisted of 28 patients (22 males and six females) and underwent wide resection of the skin and subcutaneous tissue of the natal cleft, followed by primary closure of the wound in two layers after insertion of suction drain. Group B consisted of 26 patients (22 males and four females) and underwent wide resection of the skin and subcutaneous tissue and their wounds left opened for secondary intention healing. Group C consisted of 29 patients (24 males and five females) and underwent limited excision of the fistulous tract and their wounds were left opened for secondary intention healing. Patients were followed-up for 15 to 48 months post-operatively. Demographic data, operative time, hospital stay, operative blood loss, post-operative pain, wound healing time and patient's satisfaction were recorded. RESULTS: The limited excision group of patients had a highly significant shorter operative time than the closed wound group of patients (p<0.001). They also had the shortest hospital stay, operative blood loss and post-operative pain (p<0.001). The closed wound group of patients showed significantly shortest wound healing time, followed by the limited excision group of patients; the wide excision group of patients showed the longest healing time. Apart from the minimal non-significant elevation of the rate of recurrence in the closed wound group of patients, there was no difference between the three groups. All recurrent cases were obese patients and presented within the first six months after operations. CONCLUSION: Limited excision of a pilonidal sinus represents one of the best therapeutic options. The result of this method is comparable with the more aggressive frequently used excisional method, and it has the advantage of having a shorter convalescence and better patient satisfaction.

Experience with different treatment modules in hidradenitis suppuritiva: a study of 106 cases.
Mandal A, Watson J
Surgeon. 2005 Feb;3(1):23-6.

BACKGROUND: Hidradenitis suppuritiva, a disease of the apocrine sweat glands, has always been a challenging area to the plastic and reconstructive surgeon. The aetiology is idiopathic and medical treatment offers temporary relief only. Radical surgical excision, therefore, is the mainstay of active management. AIM: To present and evaluate a series of 106 patients of hidradenitis suppuritiva treated in the regional plastic surgery unit of southeast Scotland between January 1990 and December 2000. PATIENTS: Median age at onset was 36 years (range 17-70 years). The patients were predominantly females (88.78%) and heavy smokers (98.1%). Median age before active surgical intervention was six years (range 1-30 years). The patients were divided into a mild group (n=64) and a severe group (n = 42). All patients had broad-spectrum antibiotics and multiple incision and drainage procedures before referral from general practitioners, dermatologists or general surgeons. One hundred sites were managed by primary closure (mostly in the 'mild' group); 29 resurfaced with split skin grafts and 14 with local, fasciocutaneous or musculocutaneous flaps (mostly in the 'severe' group). Median postoperative follow-up period was three years (range 1-7 years). RESULTS: In the 'primary closure' series, recurrence rate requiring at least one secondary operation was 69.88%. There was no recurrence, no serious complications and no revision operations in the 'graft' and the 'flap' series. CONCLUSION: A high index of suspicion is required before contemplating primary closure in hidradenitis suppuritiva, even in the ' mild' variety. This condition should always be treated aggressively by radical excision of all hair-bearing areas and reconstructed with a graft or a flap.

A case of subcutaneous myxopapillary ependymoma presenting as a pilonidal sinus.
Barton S, Mirza M, Fielding J
Surgeon. 2004 Oct;2(5):292-3.

We describe a rare neurogenic tumour presenting as a pilonidal sinus. This case illustrates the pitfalls associated with the management of a commonly occurring surgical condition. Pilonidal sinuses are often the province of trainee surgeons and while ependymomas are rare, this example emphasises the need to send the pilonidal sinus tract for histological examination.

Perianal Crohn's disease and infliximab therapy.
McNamara DA, Brophy S, Hyland JM
Surgeon. 2004 Oct;2(5):258-63.

INTRODUCTION: Perianal manifestations occur in almost half of patients with Crohn's disease and often respond poorly to conventional therapies. The introduction of anti-tumour necrosis factor alpha agents (e.g. infliximab) has altered the management of patients who fail first and second line medical and surgical therapies. METHODS: We performed a literature search of the PubMed database using the Medical Search Headings infliximab, perianal Crohn's disease, fistulae, cost and safety. We also performed a manual search using references from these articles, review articles and proceedings from major gastroenterology meetings. RESULTS: Use of infliximab, at a dose of 5mg/kg at intervals of 0, 2 and 6 weeks, results in significant improvement in disease in approximately 70% of patients with fistulae. Prior examination under anaesthesia with placement of non-cutting seton sutures in fistula tracks is a useful adjunct in many patients. Preliminary results show a benefit from maintenance infliximab therapy and from concomitant use of immunosuppressants such as azathioprine. No clinical or biochemical markers have been identified which predict non-response to infliximab, although its use is contraindicated in patients with strictures. Acute infusion reactions are the most common side-effect of infliximab therapy and they are usually mild. Despite initial fears, the incidence of opportunistic infection is low. There is inadequate information, at present, regarding a possible increase in incidence of lymphoma with infliximab therapy. Infliximab is expensive compared with established therapies and its use will increase the lifetime cost of treating Crohn's disease. CONCLUSION: While infliximab is a useful adjunct in selected patients, the cornerstones of management of perianal Crohn's are essentially unchanged.

Endoloops as a therapeutic option in colocutaneous fistula closure.
de Hoyos A, Villegas O, Sanchez JM, Monroy MA
Endoscopy 2005 Dec;37(12):1258.

A simple modification with the Limberg flap for chronic pilonidal disease.
Tekin A
Surgery 2005 Nov;138(5):951-3.

Superiority of Asymmetric Modified Limberg Flap for Surgical Treatment of Pilonidal Disease.
Cihan A, Ucan BH, Comert M, Cesur A, Cakmak GK, Tascilar O
Dis Colon Rectum 2005 Dec 8;.

PURPOSE: Cases treated surgically using wide excision plus classic Limberg flap or wide excision plus asymmetric modified Limberg flap were compared with respect to complications and patient comfort in the postoperative period. METHODS: In this prospective, randomized study, 68 of 70 patients were followed for a mean of 29.22 (range, 6-44) months after wide excision plus classic Limberg flap (Group 1, n = 35) and after asymmetric modified Limberg flap closure (Group 2, n = 33). RESULTS: There were significantly more macerations in Group 1 (P < 0.001). All macerations were detected on the lower part of the incision left on the intergluteal sulcus, and infections occurred subsequent to maceration. The infection rate was statistically higher in Group 1 than in Group 2 (P = 0.028). We noted that as a result of these complications, time to suture removal (P = 0.001), discharge from hospital (P = 0.001), and time off from work (P = 0.001) were significantly longer for Group 1 than for Group 2. There were two recurrences in the inferior part of the suture line in Group 1 and none in Group 2, which showed no statistical difference (P = 0.493). CONCLUSIONS: The deep intergluteal sulcus and midline gap were slightly flattened over the anococcygeal region. The vacuum effect was decreased, and there were less macerations and fewer infections. Time off from work and discharge time from hospital were shortened by eliminating the moisture effect and reducing complications by lateralizing the lower part of the suture line.

Management of Pilonidal Sinus Disease With Oblique Excision and Primary Closure: Results of 493 Patients.
Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M
Dis Colon Rectum 2005 Nov 16;.

PURPOSE: Pilonidal sinus disease is a common and well-known entity. Many surgical methods have been described for the treatment of pilonidal sinus disease. The aim of this study was to determine the advantages and long-term results of oblique excision and primary closure techniques. METHOD: Between January 1999 and December 2001, 493 patients (490 male, 3 female; average age = 23.48 +/- 3.90 (range, 15-51) years) were operated on for primary or recurrent pilonidal sinus disease. An oblique fusiform-shaped incision was made and the skin was excised. The operation was completed with primary closure. All patients' follow-up examinations were made at the end of the 6 weeks and 3, 6, 12, and 18 months after surgery. RESULTS: The mean duration of symptoms was 22.09 +/- 17.12 (range, 1-120) months. The mean duration of hospital stay was 5.51 +/- 2.85 (range, 2-17) days. At the end of the follow-up period, the recurrence rate was 5.6 percent. CONCLUSION: The ideal operation for pilonidal sinus disease treatment must be simple and effective. The technique of oblique excision and primary closure may be considered an alternative operation for pilonidal sinus resulting in a low recurrence rate.

Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula.
Quah HM, Tang CL, Eu KW, Chan SY, Samuel M
Int J Colorectal Dis 2005 Nov 30;:1-8.

BACKGROUND AND AIM: Concurrent definitive treatment of underlying fistulas from infected anal glands at the time when the anorectal abscesses are drained is controversial as this is associated with a higher incidence of faecal incontinence, failure and recurrence. This meta-analysis was conducted to determine the merits of drainage alone vs primary sphincter-cutting procedures (which includes fistulotomy and fistulectomy) for anorectal abscess-fistula. METHODS: Medline, Embase and Cochrane Central Register of Controlled Trials database searches identified all randomized controlled trials using the keywords: anorectal abscess, anal sepsis, drainage, fistulotomy, fistulectomy or surgery from 1966 to 2004. The outcome variables analysed were recurrence, faecal continence and wound-healing times. RESULTS: Five trials were considered suitable for the meta-analysis, with a total of 405 patients. Sphincter-cutting procedures for anorectal abscesses resulted in 83% reduction in recurrence rate [relative risk (RR) 0.17, 95% confidence interval (CI) 0.09-0.32, p<0.001]. However, there was a tendency to a higher risk of faecal incontinence to flatus and soiling when primary sphincter-cutting procedure was performed (RR 2.46, 95% CI 0.75-8.06, p=0.140). CONCLUSION: There is no conclusive evidence if simple drainage or sphincter-cutting procedure is better in the treatment of anorectal abscess-fistula.

What Is The Role of Mechanical Bowel Preparation in Patients with Pilonidal Sinus Undergoing Surgery? Prospective, Randomized, Surgeon-blinded Trial.
Terzi C, Canda AE, Unek T, Dalgic E, Fuzun M
World J Surg 2005 Oct 30;.

The aim of this study was to determine the effect of a mechanical bowel preparation on postoperative surgical wound infections in patients treated with identical antimicrobial prophylaxis undergoing wide excision and primary closure for chronic pilonidal sinus disease. Patients more than 18 years old were included in the study. All patients had intravenous antimicrobial prophylaxis at the time of anesthesia induction. In a prospective, randomized setting, patients were allocated to either the bowel preparation group or the no-bowel-preparation group. Mechanical bowel preparation was performed using an oral sodium phosphate solution. On the morning of the procedure a rectal enema was performed with the phosphate solution. The primary outcome measure was the rate of wound infection, but all postoperative complications and recurrences were recorded. All patients were actively observed for 1 year after discharge. The overall infection rate for the entire study population was 12.8% (13/101) including 14.3% (7/49) of those who had had the bowel preparation and 11.5% (6/52) of those with no bowel preparation. There was no statistically significant difference between groups (P = 0.680). The mean rate of recurrence for all 101 patients was 4.9% (5/101) at 19.2 months (range 12-32 months) of follow-up. The recurrence rate was 6.1% (3/49) in the bowel preparation group and 3.8% (2/52) in the no-bowel-preparation group (P = 1.000). Although the number of patients is small in this study, our results showed that the mechanical bowel preparation does not cause a decrease in the rate of surgical wound infections after excision and primary closure in patients with chronic pilonidal sinus disease.

Natalizumab induction and maintenance therapy for Crohn's disease.
Sandborn WJ, Colombel JF, Enns R, Feagan BG, Hanauer SB, Lawrance IC, Panaccione R, Sanders M, Schreiber S, Targan S, van Deventer S, Goldblum R, Despain D, Hogge GS, Rutgeerts P Trial Group.
N Engl J Med 2005 Nov 3;353(18):1912-25.

BACKGROUND: Natalizumab, a humanized monoclonal antibody against alpha4 integrin, inhibits leukocyte adhesion and migration into inflamed tissue. METHODS: We conducted two controlled trials to evaluate natalizumab as induction and maintenance therapy in patients with active Crohn's disease. In the first trial, 905 patients were randomly assigned to receive 300 mg of natalizumab or placebo at weeks 0, 4, and 8. The primary outcome was response, defined by a decrease in the Crohn's Disease Activity Index (CDAI) score of at least 70 points, at week 10. In the second trial, 339 patients who had a response to natalizumab in the first trial were randomly reassigned to receive 300 mg of natalizumab or placebo every four weeks through week 56. The primary outcome was a sustained response through week 36. A secondary outcome in both trials was disease remission (a CDAI score of less than 150). RESULTS: In the first trial, the natalizumab and placebo groups had similar rates of response (56 percent and 49 percent, respectively; P=0.05) and remission (37 percent and 30 percent, respectively; P=0.12) at 10 weeks. Continuing natalizumab in the second trial resulted in higher rates of sustained response (61 percent vs. 28 percent, P<0.001) and remission (44 percent vs. 26 percent, P=0.003) through week 36 than did switching to placebo. Serious adverse events occurred in 7 percent of each group in the first trial and in 10 percent of the placebo group and 8 percent of the natalizumab group in the second trial. In an open-label extension study, a patient treated with natalizumab died from progressive multifocal leukoencephalopathy, associated with the JC virus, a human polyomavirus. CONCLUSIONS: Induction therapy with natalizumab for Crohn's disease resulted in small, nonsignificant improvements in response and remission rates. Patients who had a response had significantly increased rates of sustained response and remission if natalizumab was continued every four weeks. The benefit of natalizumab will need to be weighed against the risk of serious adverse events, including progressive multifocal leukoencephalopathy. (ClinicalTrials.gov numbers, NCT00032786 and NCT00032799.)

Prospective, Multicenter Evaluation of Highly Concentrated Fibrin Glue in the Treatment of Complex Cryptogenic Perianal Fistulas.
Zmora O, Neufeld D, Ziv Y, Tulchinsky H, Scott D, Khaikin M, Stepansky A, Rabau M, Koller M
Dis Colon Rectum 2005 Oct 25;.

PURPOSE: The surgical management of complex perianal fistulas is challenging and may be associated with the risk of sphincter injury. Instillation of fibrin glue to the fistula tract is a simple procedure that does not involve any muscle division, and potentially results in healing of the fistula. This study was designed to assess the use of highly concentrated fibrin glue with intra-adhesive antibiotics in the treatment of complex cryptogenic perianal fistulas. METHODS: Patients with complex perianal fistulas of cryptogenic origin were prospectively included in this multicenter study. Injection of the fibrin glue mixed with antibiotics was performed in a uniform fashion. After the procedure, patients were actively examined at fixed time intervals; in cases of recurrent fistula, reinjection of fibrin glue was offered. RESULTS: Sixty patients were enrolled; complete healing of the fistula was achieved in 32 patients (53 percent). Eight of 28 patients (29 percent) who were not completely healed had significant symptomatic improvement. All patients resumed normal daily activity the day after surgery and none had any deterioration in continence related to the procedure. The majority of the 26 (43 percent) adverse events were considered mild and spontaneously resolved; 2 patients (3 percent) with perianal septic complications were successfully treated by drainage. CONCLUSIONS: Injection of fibrin glue for the treatment of perianal fistulas is safe, simple, and associated with early return to normal activity. Although moderately successful, it may preclude extensive surgery in more than one-half of these patients.

Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano.
Perez F, Arroyo A, Serrano P, Candela F, Perez MT, Calpena R
Int J Colorectal Dis 2005 Oct 20;:1-5.

BACKGROUND AND AIMS: The aim of this study was to assess the results of fistulotomy with sphincter reconstruction in the management of recurrent complex fistula-in-ano in terms of recurrence and continence. PATIENTS AND METHODS: Prospective study of 16 patients undergoing fistulotomy with sphincter reconstruction for recurrent complex fistula-in-ano was done. Preoperative and postoperative evaluation included physical examination, anal ultrasonography and anal manometry, with a 40-month follow-up. The Wexner Continence Grading Scale (0-20) was used to assess faecal continence. RESULTS: Fistulas were classified as high transsphincteric in 13 patients (81.3%), suprasphincteric in 2 (12.5%) and extrasphincteric in 1 patient (6.2%). Four patients (25%) had recurred twice or more. Eight patients (50%) complained of varying degrees of prior faecal incontinence. Their mean score decreased from 8.5 to 1.875 after surgery, and all the patients improved except for one whose score remained the same. On anal manometry, the differences between continent and incontinent patients before surgery [maximum resting pressure (MRP) 86.3 vs 57.6 mmHg, maximum squeeze pressure (MSP) 196.5 vs 138.6 mmHg] decreased after surgery (MRP 81.9 vs 63.7 mmHg, MSP 179.8 vs 159.3 mmHg). In fully continent patients, both the clinical score and manometric values were quite similar after surgery. Two fully continent patients (25%) developed occasional flatus incontinence and soiling, scoring two and three points, respectively. One patient recurred (6.25%) 6 months after surgery. CONCLUSION: Fistulotomy with sphincter reconstruction seems to be an effective resource in the management of recurrent complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.

Fistula in ano surgery has no impact on pudendal nerve terminal motor latency.
Daniel F, Thomas C, Etienney I, Atienza P
Int J Colorectal Dis 2005 Oct 18;:1-4.

BACKGROUND: Anal fistula surgery is recognized as a major risk factor for anal incontinence. This incontinence is mainly due to surgical sphincter lesions, although a neurogenic mechanism through damage to the pudendal nerve is not excluded. The objective of our study was to evaluate the influence of anal surgery on the anal terminal motor latency of the pudendal nerve (PNTML). MATERIALS AND METHODS: The PNTML values were measured pre- and postoperatively, respectively, in 33 patients (28 men, 5 women) treated for anal suppuration and 34 patients (21 men, 13 women) undergoing pedicular hemorrhoidectomy using the Milligan and Morgan technique. RESULTS: The average age was 49.6 years in the hemorrhoid group and 45 years in the fistula group (p=0.19). There was no difference in the sex ratio between the two groups (p=0.06). In the anal fistula group, the preoperative mean PNTML was 2.42 (+/-0.46) ms on the infected side and 2.40 (+/-0.42) ms on the healthy side, with a significant difference from the control group's preoperative ipsilateral latencies: 2.73 (+/-0.60) ms (p=0.02, p=0.01). The variations in the postoperative PNTML of the fistula group, both on the healthy side (DeltaPNTML=0.06+/-0.42 ms) and on the diseased side (DeltaPNTML=0.03+/-0.40 ms), are comparable with those of the hemorrhoid group (DeltaPNTML=0.01+/-0.48 ms; p=0.63, p=0.84). CONCLUSION: The nervous conduction of the pudendal nerves does not seem to be altered by the presence of an infectious process in the ischiorectal fossa nor by the surgical procedure. However, a more refined electrophysiological study would seem to be necessary to assess the repercussions on the perineal innervation.

Cancer in the anal canal, and in an anal fistula, that developed during a longstanding course of Crohn's disease.
Kazama S, Hiramatsu T, Kobayashi R, Takabayashi N, Niwa H, Isono T, Suzuki H, Shimada S, Kimura M, Hara K, Kuriki K
J Gastroenterol 2005 Oct;40(10):1000-1.

Perineal skin bridge and levator muscle preservation in neutral sagittal anorectoplasty (NSARP) for vestibular fistula.
Dave S, Shi EC
Pediatr Surg Int 2005 Sep 14;:1-4.
The incision in limited posterior sagittal anorectoplasty for vestibular fistula (VF) extends from the coccyx to the fistula with the rectum identified by partial sagittal division of the levator muscle. In anterior sagittal anorectoplasty, the perineal incision extends from the fistula opening to the posterior margin of the external sphincter complex while preserving intact the levator muscle. We describe a modification of the operation for repair of VF, the neutral sagittal anorectoplasty (NSARP), which preserves both a perineal skin bridge between the neo-anus and the posterior fourchette and the levator muscle. Leaving the perineal skin bridge and the levator muscle intact could be important both from the aspects of perineal wound-healing and functional outcome. The skin incision in NSARP extends from the coccyx to the anterior limit of the external sphincter muscle complex as defined by muscle stimulation. An artery forceps passed through the VF facilitates the location and exposure of the rectum. The levator muscle is left intact. The dissection and closure of the VF is done entirely from within the opened rectum. There is an intact perineal skin bridge between the neo-anus and the posterior fourchette at the completion of the NSARP. In 12 consecutive patients with VF, NSARP prevented the risk of wound complications occurring between the neo-anus and the posterior fourchette. A diverting colostomy was safely avoided in our last five patients. NSARP does not involve any division of the levator muscle and it also retains an undisturbed wad of tissue that could function as the perineal body. All five patients who are 3 years or older demonstrate voluntary bowel movements. Preserving the perineal skin bridge and the levator muscle in NSARP have contributed to the improvement of aesthetic appearance of the perineum and faecal continence in our patients.

Umbilical Pilonidal Sinus Disease: Predisposing Factors and Treatment.
Eryilmaz R, Sahin M, Okan I, Alimoglu O, Somay A
World J Surg 2005 Aug 11;.

Pilonidal sinus disease is a common problem of sacrococcygeal region. However, it is also observed in the periumbilical area. There are only a few reports about umbilical pilonidal sinus in the literature. In this study, 26 patients (24 men (92 %), 2 women (8 %) with a mean age of 22 years) with umbilical pilonidal sinus disease were included. Predisposing factors, patient characteristics, treatment modalities, and their results have been studied. Male sex, young age, hairiness, deep navel, and poor personal hygiene were found to be predisposing factors. Twenty-five patients were treated conservatively. However, two patients failed to respond to conservative treatment. Those patients underwent surgery where umbilectomy was carried out without reconstruction. One patient was also operated on for the preoperative misdiagnosis of irreducible umbilical hernia. Patients were followed for 14-96 months. We recommend conservative treatment in patients with umbilical pilonidal sinus. Surgery should be performed in recurrent cases resistant to conservative treatment. The importance of differential diagnosis of umbilical pilonidal sinus from other umbilical pathologies is also emphasized.

Carcinoma arising in enterocutan fistulae of Crohn's disease patients: description of two cases.
Zagoni T, Peter Z, Sipos F, Dichazi C, Tarjan Z, Dobo I, Kaszas I, Tulassay Z
Int J Colorectal Dis 2005 Aug 18;:1-4.

Rarely, carcinoma arises from the fistulous tract of Crohn's disease. Adequate radiological examination often produces misleading pseudonegative findings. We reported two cases of fistula cancers treated with infliximab. The short time-span between the administration of this drug and the diagnosis of cancer makes the correlation between the two unlikely.

Fistula-in-ano: do antibiotics make a difference?
Nunoo-Mensah JW, Balasubramaniam S, Wasserberg N, Artinyan A, Gonzalez-Ruiz C, Kaiser AM, Beart RW Jr, Vukasin P
Int J Colorectal Dis 2005 Aug 10;:1-3.

BACKGROUND: The objective of this study was to evaluate the hypothesis that antibiotics in conjunction with drainage of anorectal abscesses will reduce the incidence of fistulae formation. The impact of age and associated comorbidity on the formation of fistulae were also evaluated. METHODS: Patients with a diagnosis of anorectal abscesses were identified from the database of a single colorectal practice. Demographic data, comorbidity, antibiotic usage, and fistulae formation were collected from review of patient's charts and phone contact. Statistical analysis was performed with the two-sided Fisher's exact and Wald's chi-square tests. RESULTS: Fifty-six patients with complete data were analyzed. The overall fistulae formation rate was 32%. Of all patients, 45% received a course of broad-spectrum antibiotics at the time of drainage and 48% of patients had associated comorbidity. Although trends were evident, there were no statistical significant associations between fistulae formation and age, comorbidity, and antibiotics. CONCLUSION: Although not statistically significant, there was a trend that antibiotics and age >45 years may be protective against the formation of fistulae. Similarly, the data suggest that the presence of comorbidity may increase the risk of fistula formation. We are encouraged by this result and propose to conduct a larger randomized prospective study.

Use of endoscopic ultrasound to guide combination medical and surgical therapy for patients with Crohn's perianal fistulas.
Schwartz DA, White CM, Wise PE, Herline AJ
Inflamm Bowel Dis 2005 Aug;11(8):727-32.

BACKGROUND: This study was performed to assess if using endoscopic ultrasound (EUS) to assess and guide combination medical and surgical therapy during fistula healing will lead to a high rate of durable fistula closure and a low or absent incidence of perianal abscess formation in patients with Crohn's perianal fistulas. METHODS: This is a retrospective analysis of 21 patients who presented with a symptomatic Crohn's perianal fistula. Patients were enrolled in a clinical practice protocol of serial EUS exams. All patients underwent a baseline rectal EUS and were placed on maximal medical treatment with 6-mercaptopurine (6-MP) or azathioprine, Cipro, and infliximab (5 mg/kg at 0, 2, and 6 wk and then every 8 wk). Patients were also assessed at baseline by a colorectal surgeon who was aware of the EUS findings. Seton placement and incision and drainage were performed when appropriate. Serial EUS examinations were performed, and the findings were used to guide therapy (i.e., the presence of fistula healing on EUS was used to guide seton removal, discontinuation of infliximab, and Cipro). RESULTS: In the 21 patients enrolled, the median duration of active perianal symptoms was 9 wks (1-36). 10 patients (48%) had previous perianal surgery and 5 (24%) had received infliximab previously. The fistulas treated included 8 trans-sphincteric, 2 superficial, 3 recto-vaginal, and 7 with multiple and horseshoe fistulas. 13 patients (62%) had associated abscesses at presentation. Eighteen of 21 patients (86%) had complete cessation of drainage initially. Median time to cessation of drainage was 10.6 weeks (range, 4-32 wk). Sixteen of 21 patients (76%) maintained long-term cessation of drainage. The median length of follow-up was 68 weeks (range, 35-101 wk). No abscess developed during treatment in any patient. EUS evidence of persistent fistula activity was seen in 10 patients (48%). Of the 11 patients (52%) in whom EUS showed no persistent fistula activity, 7 (64%) have maintained fistula closure off of infliximab and Cipro. Median duration from last infliximab infusion was 47 weeks (range, 20-80 wk). The remaining 4 patients continued infliximab to maintain remission of their luminal disease. Only 1 patient with a horseshoe fistula showed complete healing on EUS. CONCLUSION: In conclusion, using EUS to guide therapy for Crohn's perianal fistulas with infliximab, an immunosuppressive, and an antibiotic is associated with a high short and long-term fistula response rate. EUS may identify a subset of patients who can discontinue infliximab without recurrence of fistula drainage.

Is Routine Cavity Drainage Necessary in Karydakis Flap Operation? A Prospective, Randomized Trial.
Gurer A, Gomceli I, Ozdogan M, Ozlem N, Sozen S, Aydin R
Dis Colon Rectum 2005 Jun 24;.

PURPOSE: Different surgical techniques for pilonidal disease have been described in the literature. In this study our aim was to evaluate the influence of routine cavity drainage in the Karydakis flap technique. METHODS: Fifty patients with pilonidal sinus who underwent the Karydakis flap operation were evaluated prospectively. The patients were assigned randomly into two groups-with and without suction drainage of the cavity-and the effects of drains were studied in terms of wound complications, hospital stay, and recurrence rate. RESULTS: There was no significant difference between groups in term of length of hospital stay. Complication rate was 20 percent and the complications were caused exclusively by fluid collections. Wound infection, dehiscence, or failure was not observed in any of the patients. There has been no recurrence in any of the patients during the follow-up period. There was a significant increase in the number of fluid collections in patents without a suction drain. CONCLUSION: The present study indicates that routine cavity drainage reduces the incidence of fluid collection after the Karydakis flap operation.

Is perianal Crohn's disease associated with intestinal fistulization?
Sachar DB, Bodian CA, Goldstein ES, Present DH, Bayless TM, Picco M, van Hogezand RA, Annese V, Schneider J, Korelitz BI, Cosnes J
Am J Gastroenterol 2005 Jul;100(7):1547-9.

BACKGROUND: When cases of Crohn's disease (CD) are described as "fistulizing," distinctions are often not drawn between perianal and intestinal fistulization. The question, therefore, remains open as to whether or not there is truly an association between perianal fistulization and intraabdominal intestinal fistulization in CD. AIMS: We have sought to determine the association between perianal and intestinal fistulization by analyzing the cases of CD recorded in databases from six international centers. PATIENTS: Six databases provided information on 5491 cases of CD in the United States, France, Italy, and The Netherlands. Of these cases, 1686 had isolated ileal disease and 1655 had Crohn's colitis. METHODS: An association between perianal disease and internal fistulae was sought by calculating relative risks for the chance of internal fistulae among patients with perianal fistulae relative to those without. Statistical significance was calculated by the Mantel-Haenszel procedure, stratifying on the separate centers. All statistical tests and estimates were implemented using SAS for the PC. RESULTS: Among the 1686 cases with isolated ileal disease, the evidence of an association between perianal disease and internal fistulization was not consistent across centers, with relative risks ranging from 0.8 to 2.2. For patients with Crohn's colitis (n = 1655), the association was much stronger and more consistent, with an estimated common relative risk of 3.4, 95% confidence interval (2.6-4.6, p < 0.0001). CONCLUSIONS: We have found a statistically significant association between perianal CD and intestinal fistulization, much stronger and more consistent in cases of Crohn's colitis than in cases limited to the small bowel. (Am J Gastroenterol 2005;100:1-3).

The mycobacteria story in Crohn's disease.
Shanahan F, O'mahony J
Am J Gastroenterol 2005 Jul;100(7):1537-8.

The heterogeneity of Crohn's disease suggests that it would be unwise to dismiss an infectious contribution to the pathogenesis in a subset of patients. The most enduring infectious candidate has been Mycobacterium paratuberculosis, which appears to be widespread in nature and appears to have the potential to infect humans. However, there are many counterarguments to the notion that MAP causes Crohn's disease, and numerous observations are seemingly at variance with this concept. (Am J Gastroenterol 2005;100;1537-1538).

Enterocutaneous fistula complicating a duodenal bezoar: An unusual presentation.
Elhajj II, Abbas J, Tawil AN, Mourad FH.
Gastrointest Endosc 2005 Jun;61(7):877-8.

Implantation metastasis from adenocarcinoma of the colon into a fistula-in-ano: a case report.
Gupta R, Kay M, Birch DW. Can
J Surg 2005 Apr;48(2):162-3.

A gastrocolic fistula in Crohn's disease.
Ruffolo C, Angriman I, Scarpa M, D'Odorico A, Polese L, Barollo M, Bertin M, Pagano D, D'Amico DF.
Dig Dis Sci 2005 May;50(5):933-4.

Internal Anal Sphincter Preservation With Seton Rerouting in High Transsphincteric Anal Fistula.
Zbar AP, Pescatori M.
Dis Colon Rectum 2005 May 27;.

The Authors Reply.
Athanasiadis S, Helmes C, Yazigi R, Kohler A.
Dis Colon Rectum 2005 May 26;.

A Phase I Clinical Trial of the Treatment of Crohn's Fistula by Adipose Mesenchymal Stem Cell Transplantation. Garcia-Olmo D, Garcia-Arranz M, Herreros D, Pascual I, Peiro C, Rodriguez-Montes JA. Dis Colon Rectum 2005 May 17;.
PURPOSE: The effective management of fistulas in patients with Crohn's disease presents an extremely challenging problem. Mesenchymal adult stem cells extracted from certain tissues, such as adipose tissue, can differentiate into various cell types. Therefore, we have tried to use such cells to stimulate healing of Crohn's fistulas. METHODS: We designed a prospective Phase I clinical trial, involving five patients with Crohn's disease, to test the feasibility and safety of autologous stem cells transplantation in the treatment of fistulas. We also studied the expression of various cell markers and the growth rates of the lipoaspirate-derived cells that were used for transplantation. RESULTS: One patient was excluded because of bacterial contamination of cultured cells. We inoculated nine fistulas in four patients with autologous adipose tissue-derived stem cells at Passage 3 or earlier. Eight inoculated fistulas were followed weekly for at least eight weeks. In six fistulas, the external opening was covered with epithelium at the end of Week 8, and, thus, these fistulas were considered healed (75 percent). In the other two fistulas, there was only incomplete closure of the external opening, with a decrease in output flow (not healed; 25 percent). No adverse effects were observed in any patient at the end of the follow-up period (minimum follow-up,12 months; maximum follow-up, 30 months; follow-up average, 22 months). CONCLUSIONS: To our knowledge, this is the first report of a clinical trial of cell therapy using autologous stem cells obtained from a lipoaspirate. Our results indicate that our protocol is feasible and safe for the treatment of fistulas in Crohn's disease. The number of patients included and the uncontrolled nature of Phase I clinical trials do not allow demonstration of the effectiveness of the treatment. However, the results of the present study encourage to perform further studies in Phase II.

Practice Parameters for the Treatment of Perianal Abscess and Fistula-in-Ano (Revised).
Whiteford MH, Kilkenny J 3rd, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G. Dis Colon Rectum 2005 May 17;.

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. . . Clinical Practice Guidelines based on the best available evidence. . . . The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Fibrin Glue in the Treatment of Pilonidal Sinus: Results of a Pilot Study.
Lund JN, Leveson SH
Dis Colon Rectum 2005 Mar 28;.

INTRODUCTION: Pilonidal sinus is a common condition of uncertain etiology. There is no agreed best surgical treatment. Treatment of fistula-in-ano has been described with some success with fibrin tissue glue. The use of fibrin glue is investigated in this pilot study. METHODS: Six patients with chronic pilonidal sinus were treated with injection of fibrin tissue glue after curettage of the pits. RESULTS: There were no complications. Postoperative discomfort was minimal and early return to normal activities was possible. There was no recurrence of disease in five of six patients at one year. CONCLUSIONS: Fibrin tissue glue may be a possible novel treatment for pilonidal disease.

Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulizing Crohn's disease.
Lichtenstein GR, Yan S, Bala M, Blank M, Sands BE
Gastroenterology 2005 Apr;128(4):862-9.

BACKGROUND & AIMS: Infliximab is effective in closing fistulas in patients with Crohn's disease. We examined the effect of infliximab maintenance treatment on hospitalizations, surgeries, and procedures in patients with fistulizing Crohn's disease enrolled in the ACCENT II study. METHODS: After 5 mg/kg infliximab at weeks 0, 2, and 6, a total of 282 patients were separately randomized at week 14 as responders (at least a 50% reduction from baseline in the number of draining fistulas at both weeks 10 and 14) or nonresponders to receive placebo or 5 mg/kg infliximab maintenance every 8 weeks. At week 22 and later, patients who lost response could be treated with a maintenance dose 5 mg/kg higher. Data on Crohn's disease-related hospitalizations, surgeries, and procedures were compared between the treatment groups for responders and all randomized patients. RESULTS: A total of 282 patients were randomized at week 14, of whom 195 were randomized as responders. Among patients randomized as responders, those who received infliximab maintenance had significantly fewer mean hospitalization days (0.5 vs. 2.5 days; P < .05), mean numbers (per 100 patients) of hospitalizations (11 vs. 31; P < .05), all surgeries and procedures (65 vs. 126; P < .05), inpatient surgeries and procedures (7 vs. 41; P < .01), and major surgeries (2 vs. 11; P < .05), compared with those who received placebo maintenance. CONCLUSIONS: In patients with fistulizing Crohn's disease, infliximab 5 mg/kg every 8 weeks significantly reduced hospitalizations, surgeries, and procedures compared with placebo.

Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature.
Coremans G, Margaritis V, Van Poppel HP, Christiaens MR, Gruwez J, Geboes K, Wyndaele J, Vanbeckevoort D, Janssens J
Dis Colon Rectum 2005 Mar;48(3):575-81.

Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.

Treatment of pilonidal sinus by phenol application and factors affecting the recurrence.
Kaymakcioglu N, Yagci G, Simsek A, Unlu A, Tekin OF, Cetiner S, Tufan T
Tech Coloproctol 2005 Apr;9(1):21-4.

BACKGROUND : Phenol injection, a less invasive method, has become more popular for the treatment of sinus pilonidalis. Recurrence rates after the use of phenol have been reported to be less than those after other surgical methods. METHODS : In this study, we applied 80% phenol to 143 patients with sinus pilonidalis. Patients were reevaluated at 1, 3, 6, 12 and 24 months after the phenolization procedure to search for any recurrences. Age, sex, skin color, occupation, hair distribution, complaints, macroscopic characteristics of the lesion, pouch volume, microbiological yield, complications of phenol injection, healing time, and recurrences were determined. RESULTS : The mean follow-up period was 24 months and the recurrence rate was 8.3% (12 of 143 patients). Volume of the sinus tract and number of sinus orifices were determined to be the factors significantly affecting recurrences (p<0.05). CONCLUSIONS : Injection of 80% phenol is an ideal approach for the conservative treatment of sinus pilonidalis. This study confirms that this is an effective and costless method with low recurrence rates.

Endoanal ultrasound-guided needle drainage of intersphincteric abscess.
Epstein J, Giordano P
Tech Coloproctol 2005 Apr;9(1):67-9.

Traditional management of intersphincteric abscess is by incision and drainage involving division of fibres of the internal sphincter. Here, a less invasive method is described. Three patients with intersphincteric abscess identified by endoanal sonography were treated by ultrasound-guided needle aspiration under anaesthesia. None of the patients had complications or required postoperative wound care. All patients remained asymptomatic at a mean follow-up of 15.7 months (range, 12-18 months). Endoanal ultrasound-guided aspiration is a simple and safe method for the treatment of intersphincteric abscess.

A case of perforation and fistula formation resulting from metallic stent for sigmoid colon stricture in Crohn's disease.
Wada H, Mochizuki Y, Takazoe M, Matsuhashi N, Kitou F, Fukushima T
Tech Coloproctol 2005 Apr;9(1):53-6.

A 52-year-old male was diagnosed with Crohn's disease at the age of 25 years. Thereafter, he underwent three operations for intestinal strictures or fistula. A self-expanding metallic stent was inserted into the sigmoid colon stricture endoscopically in November 1999. Thirty two months later, he presented left lower abdominal pain. Endoscopic and radiographic examinations demonstrated perforation of the stent and ileosigmoid fistula. Laparotomy revealed an inflammatory mass around the sigmoid colon, and the wire frame of the metallic stent had penetrated the colonic wall and had fistulized to the ileum. The affected sigmoid colon was resected and low anterior resection and ileostomy were performed. Metallic stent for intestinal stricture of Crohn's disease with active ulceration may postpone surgery temporarily but can be a potentially dangerous procedure.

Perianal Crohn Disease: Predictors of Need for Permanent Diversion.
Galandiuk S, Kimberling J, Al-Mishlab TG, Stromberg AJ
Ann Surg 2005 May;241(5):796-802.

OBJECTIVE: Fissures, fistulas, abscesses, and anal canal stenosis are manifestations of perianal Crohn disease (CD). There are no known predictors of which patients will fail sphincter-sparing surgical therapy and ultimately require fecal diversion. METHODS: Of 356 consecutive patients with CD, 24% (86) had perianal CD (age range, 14-83 years), and women were slightly more frequently affected. Clinical variables were examined for factors predictive of the need for permanent fecal diversion. RESULTS: CD associated with perianal CD was limited to the small bowel and/or ileocolic area in 23% of patients; the remainder had colorectal CD. Eighty-six patients underwent 344 operations. Forty-two patients (49%) ultimately required permanent diversion; among them were 21 of 32 patients (66%) with anal stricture and 12 of 20women (60%) with rectovaginal fistula. Univariate analyses of clinical variables were performed with respect to need for permanent fecal diversion. Significant univariate predictors were the presence of colonic CD (P = 0.0045, odds ratio [OR] 5.4), avoidance of ileocolic resection (P = 0.0147, OR 0.4), and the presence of an anal stricture (P = 0.0165, OR 3.0). In multivariate logistic regression, the presence of colonic disease and anal canal stricture were predictors of permanent diversion. The OR associated with the risk of permanent diversion in the presence of colonic disease and in the absence of anal stricture was 10 (P = 0.0345). In the presence of both colonic disease and anal canal stenosis, the OR associated with permanent stoma was 33 (P = 0.0023). CONCLUSIONS: The management of perianal CD continues to be challenging. Roughly half of patients required permanent fecal diversion, which was even more frequently true for patients with colonic CD and anal stenosis. Recognizing these tendencies will assist both patients and surgeons in planning optimal treatment.

Smoking Impairs Rectal Mucosal Bloodflow-A Pilot Study: Possible Implications for Transanal Advancement Flap Repair.
Zimmerman DD, Gosselink MP, Mitalas LE, Delemarre JB, Hop WJ, Briel JW, Schouten WR
Dis Colon Rectum 2005 Apr 14;.

Transanal advancement flap repair has been advocated as the treatment of choice for transsphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26-69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8-70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7-35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.

Differentiation of Perianal Fistulas with Digital Subtraction Magnetic Resonance Fistulography.
Schaefer O, Lohrmann C, Kreisel W, Rasenack J, Ruf G, Hopt U, Langer M
Inflamm Bowel Dis 2005 Apr;11(4):383-387.

BACKGROUND: Pelvic magnetic resonance imaging (MRI) is accurate in identifying perianal fistulas. The exact visualization of fistulous tracts and concomitant abscesses determine the type of treatment. To improve the detection of perianal fistulas, we studied digital subtraction MR-fistulography for tissue differentiation based on signal intensity measurements. METHODS: This study included 75 patients with the clinical diagnosis of perianal fistula. All patients were analyzed by a thin-slice, high-resolution, fast low-angle shot 3-dimensional sequence in the axial plane before and after intravenous injection of gadobenate dimeglumine, followed by image subtraction. Operator-defined regions of interest were used to calculate signal intensities of the inflamed fibrous walls of fistulas, the common femoral artery, the internal and external sphincter muscles, and the gluteus muscle. The fistulas were classified according to Parks classification. RESULTS: Based on signal intensity measurements in 75 patients with perianal fistulas, diagnosed by digital subtraction MR-fistulography, a significant differentiation between fistulous tracts and anatomic structures was possible. MRI identified 116 perianal fistulas (34 intersphincteric, 33 transsphincteric, 10 suprasphincteric, and 39 extrasphincteric) and 35 abscesses. CONCLUSIONS: Digital subtraction MR-fistulography is a new, promising, noninvasive imaging technique for the detection of perianal fistulas and abscesses.

High Body Mass Index as a Possible Risk Factor for Pilonidal Sinus Disease in Adolescents.
Arda IS, Guney LH, Sevmis S, Hicsonmez A
World J Surg 2005 Mar 22;.

Pilonidal sinus disease (PSD) is common in adults, but it may also develop in adolescents. The intergluteal groove is a deep moist area in which broken hairs and foreign bodies can collect, often leading to infection. Only a few papers have been published considering PSD in children. For the present study, we retrospectively examined the data of operated patients with PSD. From that review, it appears that high body mass index (BMI) might be a risk factor for the development of PSD and its complications in older children. Fourteen young patients (12 males, 2 females, 12-18 years of age) underwent surgery for PSD. According to the BMI-for-age, eight of these patients (57, 1%) were overweight or obese. Five of them (35.8%) developed mild to moderate postoperative complications. Symptoms recurred in one patient (7.1%) whose BMI was considered as overweight. In patients with normal weight no early or late complications developed. Our findings suggest that high BMI in adolescents is a significant risk factor in the development of both symptoms and complications of PSD after surgical treatment.

Treatment of Fistulas-in-Ano With Fibrin Sealant in Combination With Intra-adhesive Antibiotics and/or Surgical Closure of the Internal Fistula Opening.
Singer M, Cintron J, Nelson R, Orsay C, Bastawrous A, Pearl R, Sone J, Abcarian H
Dis Colon Rectum 2005 Mar 22;.

PURPOSE: The treatment of fistulas-in-ano with fibrin sealant injection has been moderately successful. Failures can be caused by persistent infection within the tract or early expulsion of the clot. In an attempt to improve the success rate, we examined three modifications of the sealant procedure: the addition of cefoxitin to the sealant, surgical closure of the primary opening, or both. METHODS: A prospective, randomized, clinical trial was performed in which patients were treated with Tisseel-VH ((R)) fibrin sealant according to previously published procedures. In addition, patients were randomized to receive intra-adhesive cefoxitin, surgical closure of the primary opening, or both modifications. Cefoxitin, 100 mg, was added to the sealant for patients randomized to receive intra-adhesive antibiotics. For the appropriate patients, the primary fistula opening was closed with a 3-0 absorbable suture. If fistulas failed to heal, patients were offered a single retreatment with sealant. RESULTS: Twenty-four patients were treated in the cefoxitin arm, 25 in the closure arm, and 26 in the combined arm. Median duration of fistulas was 12 months. Patients were followed for a mean of 27 months postoperatively. There was no postoperative incontinence or complications related to the sealant itself. Initial healing rates were 21 percent in the cefoxitin arm, 40 percent in the closure arm, and 31 percent in the combined arm (P = 0.35). One of five patients in the cefoxitin arm, one of seven patients in the closure arm, and one of six patients in the combined arm were successfully retreated; final healing rates were 25, 44, and 35 percent respectively (P = 0.38). CONCLUSIONS: Treatment of fistula-in-ano with fibrin sealant with closure of the internal opening was somewhat more successful than sealant with cefoxitin or the combination, however this did not achieve statistical significance. None of the three modifications were more successful than historic controls at our institution treated with sealant alone. Therefore, the addition of intra-adhesive cefoxitin, closure of the internal opening, or both are not recommended modifications of the fibrin sealant procedure.

Rectovaginal fistulas after rectal cancer surgery: Incidence and operative repair by gluteal-fold flap repair.
Kosugi C, Saito N, Kimata Y, Ono M, Sugito M, Ito M, Sato K, Koda K, Miyazaki M
Surgery 2005 Mar;137(3):329-36.

Background We investigated the correlation between operative procedures for rectal carcinoma and
postoperative rectovaginal fistulas (RVF), and treatment for RVF. Methods The medical records of 161 female patients with rectal carcinoma were examined retrospectively with respect to the cause, incidence, and methods of treatment for RVF occurring after rectal cancer operations, and to the outcomes of gluteal-fold flap repairs for RVF. Results Of the 161 patients, 16 developed RVF clinically. The incidence of RVF was significantly higher in patients who were anastomosed by the double stapling technique (DST) and had concomitant resection of the vaginal wall. No statistical difference was found between the established diverting ostomy group and the no-stoma group. Six patients recovered by the establishment of a diverting ostomy only. The gluteal-fold flap technique was performed for 5 patients. No RVF recurrences were noted in these 5 patients. Conclusions The incidence of RVF was higher in the patients who were anastomosed by DST or had concomitant resection of the vaginal wall. Although some RVFs heal with only fecal diversion, for patients in whom RVF is caused by involvement of the vaginal wall in the circular staple or intersphincteric resection, good results are obtained with the gluteal-fold flap repair technique

V-Y advancement flap closures for complicated pilonidal sinus disease.
Berkem H, Topaloglu S, Ozel H, Avsar FM, Yildiz Y, Yuksel BC, Hengirmen S, Akyurek N
Int J Colorectal Dis 2005 Mar 4;.

BACKGROUND AND AIMS: Hair entry into the midline is the generally accepted theory in pilonidal sinus formation. This theory is also involved in the pathogenesis of the recurrence after different types of operations for pilonidal sinus disease. The relationship of the suture lines and the midline was evaluated in this study. PATIENT AND METHODS: Thirty-four patients with stage 4 or recurrent pilonidal sinus disease who underwent V-Y advancement flap closure were randomized into two groups: vertical suture line unrelated to midline (VLUM, n=18) and vertical suture line related to midline (VLRM, n=16). RESULTS: None of the patients with or without a suction drain developed flap necrosis, local haematomas or seromas. The median length of the postoperative hospital stay was 3 days for theVLRM group and the VLUM group (p>0.05). The median follow-up period was 32 months. During the follow-up period, two recurrences were determined 22 and 15 months after operation in the VLRM group. Recurrences were situated in the scar tissue over the midline. INTERPRETATION AND CONCLUSION: Routine application of suction drains is not recommended after V-Y advancement flap closure. Avoidance of the relationship of the postoperative suture line and the midline, if possible, offers a safe method of definitive reconstruction.

Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus A prospective, randomized clinical trial
Gencosmanoglu R, Inceoglu R
Int J Colorectal Dis 2005 Feb 16;.

BACKGROUND AND AIMS: The best surgical technique for treating pilonidal sinus disease is controversial. The aim of this study is to compare the modified lay-open technique with primary closure following excision with respect to operating time, healing time, time before return to work, morbidity rate, and recurrence rate. PATIENTS AND METHODS: After a pre-study power analysis, 142 patients with chronic sacrococcygeal pilonidal sinus were prospectively and randomly allocated, either to the modified lay-open group (Group A, n=73) or the primary closure group (Group B, n=69). In the former, incision, curettage, partial lateral wall excision, and marsupialization were performed. Single doses of cefazoline (1 g) and metronidazole (500 mg) were given intravenously 15 min before surgery to all patients. RESULTS: There were no differences with respect to gender, age, body mass index, and mean operating time between the groups. In Group A, healing failure and early bridging occurred in one patient each. In Group B, wound infection occurred in four patients, wound breakdown in three, one healing failure and hematoma in one patient each. Morbidity and recurrence rates were significantly lower in Group A (2.7 vs. 13%, P=0.028 and 1.4 vs. 17.4%, P<0.001 respectively). The median time before return to work in Group A was significantly shorter than in Group B (3 [range 2-8] vs. 21 [range 14-63] days, P<0.001). The median healing time in Group A was significantly longer than in Group B (7 [range 3-16] weeks vs. 2 [range 2-9] weeks; P<0.001). CONCLUSION: The results of the present study suggest that modified lay-open is superior to excision with primary closure for the surgical treatment of chronic sacrococcygeal pilonidal sinus with regard to morbidity and recurrence rates, and time before return to work, although healing time is longer.

Malignant transformation of chronic perianal Crohn's fistula.
Bahadursingh AM, Longo WE
Am J Surg 2005 Jan;189(1):61-

Enterocutaneous fistula due to polypropylene mesh migration.
Acar T, Gomceli I, Tacyildiz R, Sozen S, Karakayali S, Aydin R
Ir J Med Sci 2002 Jul-Sep;171(3):172, 174

Long-Term Indwelling Seton for Complex Anal Fistulas in Crohn's Disease.
Thornton M, Solomon MJ
Dis Colon Rectum 2005 Mar 2;.

PURPOSE: This study was designed to review the results of long-term indwelling seton or depezzar catheter in the management of perianal Crohn's disease. METHODS: A retrospective case review from data extracted from a prospective endorectal ultrasound database was performed. All patients underwent an intraoperative endorectal ultrasound to identify the extent of the fistulas and to assess anal wall thickness. Fistulas were classified by Parks' criteria. All patients then underwent insertion of a seton or depezzar catheter under ultrasound guidance. All patients were followed clinically and with endorectal ultrasound by the senior author. Outcome measures included symptom control, number of procedures required, fecal continence, and reduction in anal wall thickness. RESULTS: Twenty-eight patients with 43 complex perianal Crohn's fistulas were identified. Median follow-up was 13 (range, 2-81) months. Twenty-one percent of patients developed recurrent or new perianal symptoms while the seton was in situ. Eleven percent of patients required further surgical intervention. The median anal wall thickness at the time of diagnosis was 18.5 mm reducing to a median of 14 mm after seton insertion and symptom control (P < 0.02). No patient reported a deterioration in fecal continence after seton insertion. In multivariate analysis, patient age (P < 0.005), reduction in anal wall thickness after seton insertion (P < 0.04), and length of follow-up (P < 0.03) were significant predictors of long-term symptom control. CONCLUSIONS: Long-term indwelling seton is an effective management modality for complex perianal Crohn's fistulas, which does not negatively impact fecal continence. Clinical symptoms and course are associated with anal wall thickness as measured by endorectal ultrasound.

Pilot Study: Fibrin Sealant in Anal Fistula Model.
Buchanan GN, Sibbons P, Osborn M, Bartram CI, Ansari T, Halligan S, Cohen CR
Dis Colon Rectum 2005 Feb 10;.

PURPOSE: The aim of this study was to investigate the failure of fibrin sealant treatment for fistula-in-ano in an experimental porcine model and to determine histologic changes associated with the sealant and setons.METHODS: Three surgically created fistulas were treated by seton drainage in each of eight male pigs. After 26 days, magnetic resonance imaging was performed and setons were removed. Two pigs were killed as controls for stereologic histologic fistula track assessment. In six, fistulas were curetted, and in four the fistulas were treated with fibrin sealant. In these four sealant and two seton pigs, magnetic resonance imaging was repeated a median of 47.5 days after fistula formation. The pigs were killed and stereologic histologic fistula track examination was performed to determine granulation tissue and fistula lumen volumes. These values were compared among control, seton, and sealant groups over time, and related to fistula volumes derived from magnetic resonance imaging.RESULTS: Sealant was not visible microscopically within tracks, although some sections revealed a foreign body-type reaction. On stereologic assessment, granulation tissue volumes were smaller in sealant and seton groups than in controls (median, 88 vs. 187 vs. 453 mm(3), respectively; P = 0.002) and decreased over time (median, 408 and 152 mm(3) (Day 42) vs. 88 and 75 (Day 53), respectively; P = 0.002). Fistula lumen (P < 0.001), and granulation tissue combined with fistula lumen volumes (P = 0.002) were similarly smaller. Magnetic resonance imaging of fistula intensity was less in the sealant group than in the seton group and controls (mean, 777 vs. 978 vs. 1214 units/mm(2), P = 0.003). Magnetic resonance imaging fistula volumes were least in sealant and seton groups vs. controls (P = 0.024), decreasing significantly in the sealant group over time (P = 0.018). No direct relationship was found between imaging and histologic volumes.CONCLUSIONS: In an experimental porcine model of anal fistula, granulation tissue was still present, albeit diminished, following track curettage combined with seton or sealant therapy, and was minimal in the sealant group, confirming some benefit from this procedure. Eradication of all longstanding granulation tissue may ensure complete success of fibrin sealant therapy.

Experimental Model of Fistula-In-Ano.
Buchanan GN, Sibbons P, Osborn M, Bartram CI, Ansari T, Halligan S, Cohen CR
Dis Colon Rectum 2005 Feb 15;.

PURPOSE: This study was designed to create and evaluate an experimental porcine model of fistula-in-ano. METHODS: Initial cadaveric dissection enabled refinement of the technique for fistula formation and histoanatomical study of the porcine anal canal. Subsequently, three surgically created fistulas were treated by seton drainage in each of eight male pigs (weight, 38-41 kg). After 26 days, magnetic resonance imaging at 1.5 Tesla was performed and setons removed under general anesthesia, enabling clinical and microbiologic track assessment. Two pigs were killed for histologic fistula track assessment. RESULTS: Histoanatomical assessment noted a rudimentary internal anal sphincter, together with structures resembling anal glands. Artificial fistulas persisted during seton drainage and were more often associated with fecal than skin-derived organisms compared with both perineal and anal canal swabs (P = 0.002). All six fistulas assessed histologically had a lumen, and abundant surrounding granulation tissue similar to that seen in human fistula-in-ano. Epithelialization was not evident in any track. Fistulas were visualized as high signal tracks using magnetic resonance imaging. CONCLUSIONS: Porcine anal anatomy resembles that of humans, and an experimental model proved suitable when assessed by magnetic resonance imaging, microbiology, and histologically, which demonstrated abundant granulation tissue. This model could be further used to investigate fistula treatments.

Management and Outcome of Pouch-Vaginal Fistulas Following Restorative Proctocolectomy.
Heriot AG, Tekkis PP, Smith JJ, Bona R, Cohen RG, Nicholls RJ
Dis Colon Rectum 2005 Mar 2;.

PURPOSE: The aim of this study was to assess the short-term and long-term outcomes of surgical repair of patients with pouch-vaginal fistulas after restorative proctocolectomy. METHODS: A descriptive study was undertaken of all patients developing pouch-vaginal fistulas following restorative proctocolectomy between 1978 and 2003 in a single tertiary referral institution. Kaplan-Meier survival analysis was used to evaluate the time to first pouch-vaginal fistula recurrence and pouch-vaginal fistula-free survival at last follow-up. RESULTS: Sixty-eight patients (mean age, 32.2 years; standard deviation, 10.7) were identified with a median follow-up of 5.5 (range, 0.2-25.5) years. The origin of the pouch-vaginal fistulas was the pouch-anal anastomosis in 52 (76.5 percent) patients, pouch body/top in 9 (13.2 percent), or cryptoglandular or other source in 7 (10.3 percent). Associated early complications in patients with pouch-vaginal fistulas included pelvic sepsis in 20 (29 percent) patients, anastomotic separation in 6 (24 percent), anastomotic stricture in 16 (24 percent), small bowel obstruction in 17 (25 percent), hemorrhage in 2 (3 percent), or pouchitis in 12 (18 percent). Surgery was undertaken in 59 (87 percent) patients with 14 (20.6 percent) of them undergoing pouch excision/diversion or seton drainage. Forty-five (66 percent) patients underwent primary repair. First recurrence of pouch-vaginal fistula occurred in 27 of 45 (60 percent) patients with a median pouch-vaginal fistula-free interval of 1.6 years (95 percent confidence interval, 0.6-2.7). Fourteen (51.9 percent) patients with recurrent pouch-vaginal fistulas healed following one or more repeat procedures. The diagnosis of Crohn's disease was made in eight (12 percent) patients, with pouch-vaginal fistulas persisting or recurring in all patients with Crohn's disease within five years of the primary treatment. Median pouch-vaginal fistula-free survival was 1.4 years for patients with Crohn's disease and 8.1 years for patients with ulcerative colitis or familial adenomatous polyposis. The pouch-vaginal fistula-free survival improved with repeated local or abdominal repairs for patients with ulcerative colitis. The overall pouch failure rate for patients with pouch-vaginal fistulas was 35 percent (median pouch survival, 4.2 years). CONCLUSIONS: Pouch-vaginal fistulas can persist and recur indefinitely, even after repeated repairs. Repair in those patients with Crohn's disease uniformly failed within five years from primary repair. Patients with recurrent pouch-vaginal fistulas and ulcerative colitis should be offered salvage surgery because successful closure following initial failure occurs in approximately 50 percent.

Anti-TNF-alpha (Infliximab) Used as Induction Treatment in Case of Active Proctitis in a Multistep Strategy Followed by Definitive Surgery of Complex Anal Fistulas in Crohn's Disease: A Preliminary Report.
van der Hagen SJ, Baeten CG, Soeters PB, Russel MG, Beets-Tan RG, van Gemert WG
Dis Colon Rectum 2005 Mar 4;.

PURPOSE: This study was designed to assess the healing rate of complex perianal fistulas in Crohn's disease after a multistep strategy, including induction treatment with In-fliximab in case of active proctitis, followed by definitive surgery. METHODS: From 2000 to 2003, all consecutive patients with complex fistulas and Crohn's disease underwent pretreatment with noncutting setons and, in case of severe recurrent fistulas or abscesses, a diverting stoma. Infliximab was added in cases of active proctitis. After definitive surgical treatment, patients were examined. RESULTS: Seventeen patients were included (median age, 34 (range, 22-58) years). Seven patients were treated by surgery only, and in ten patients Infliximab was added. After a median follow-up of 19 (range, 8-40) months, fistula healing was observed in 17 patients (100 percent). One patient of the Infliximab group developed a recurrent fistula (10 percent) after 24 months, and in one patient (10 percent) soiling occurred. Two patients of the surgical group developed a recurrent fistula (29 percent) and soiling occurred in two patients (29 percent). CONCLUSIONS: A multistep strategy followed by definitive surgery for the treatment of complex perianal fistulas in patients with Crohn's disease is a promising treatment modality. The preliminary results of this study suggest that Infliximab treatment has a beneficial additive effect in the multistep treatment followed by definitive surgery of complex anal fistulas and active proctitis in Crohn's disease.

Lymphoma creating colojejunal fistula: report of a case and review of the literature.
McMahon LE, Tessier DJ, Devine RM, McConnell EJ
Dis Colon Rectum 2005 Jan;48(1):158-61.

Malignant fistula of the colon to the small bowel is rare and is most often due to adenocarcinoma. Colonic lymphoma is unusual, representing only 0.5 percent of all colonic malignancies. We report a case of intestinal lymphoma presenting with diarrhea and malnutrition. A colojejunal fistula was discovered during colonoscopy by biopsy of small bowel through a fistula in the sigmoid colon. Celiotomy revealed a 12 cm mass in the sigmoid colon with a fistula to the jejunum. Pathology was consistent with T-cell lymphoma. This is a rare entity in a nonimmunocompromised host and has not been described in the English literature.

Anocutaneous V-Y advancement flap for the treatment of complex perianal fistula.
Sungurtekin U, Sungurtekin H, Kabay B, Tekin K, Aytekin F, Erdem E, Ozden A
Dis Colon Rectum 2004 Dec;47(12):2178-83.

PURPOSE: The treatment of intersphincteric and low transsphincteric fistula is well defined, but controversy remains around the management of complex perianal fistula. This study was designed to assess the utility of anocutaneous flap repair in complex types of perianal fistula. METHODS: Sixty-five perianal fistula in 65 patients treated with anocutaneous advancement flap for the complex fistula, between April 1998 and December 2002, are included this prospective study. Mean age was 34 +/- 2.1 (range, 24-53) years. Magnetic resonance imaging was used for the diagnosis of fistula. Excision of the internal opening and the overlying anoderm, curettage of the fistula tract, closure of internal opening with absorbable polyglactin 3/0 suture, and drainage of the external opening(s) by insertion of penrose drain were common operational steps. Outcome was evaluated in terms of healing and incontinence. RESULTS: Successful healing of 59 of 65 complex fistulas was achieved using this technique with no disturbance of continence and minimal complications. Mean follow-up and complete healing time were 32 +/- 0.6 (range, 12-52) months and 5.4 +/- 0.8 (range, 3-7) weeks respectively. CONCLUSIONS: Although the study cases were relatively small in number, this report showed that clinical results of anocutaneous advancement flap are acceptable. However, large studies are needed to reach an ultimate conclusion for assessing the place of anocutaneous flap advancement in complex fistula.

Laparoscopic sigmoidectomy for fistulized diverticulitis.
Laurent SR, Detroz B, Detry O, Degauque C, Honore P, Meurisse M
Dis Colon Rectum 2005 Jan;48(1):148-52.

PURPOSE: Nowadays laparoscopic colorectal surgery has demonstrated its advantages, including reduced postoperative pain, decreased duration of ileus, and shorter hospital stay. Few studies report results of laparoscopic surgery in complicated diverticulitis. This study was designed to analyze the results of laparoscopic sigmoidectomy in patients with fistulized sigmoiditis. METHODS: The authors retrospectively reviewed 16 patients who had laparoscopic sigmoidectomy for fistulized diverticulitis between 1992 and 2003 in a series of 247 laparoscopic colectomies. Eleven patients presented with colovesical, four with colovaginal, and one with colocutaneous fistulas; all were caused by sigmoiditis. The procedure always consisted of celioscopic sigmoidectomy with stapled transanal suture and, when indicated, closure of the cystic or vaginal fistula orifice. RESULTS: Mean age was 60 (range, 39-78) years. Mean number of episodes of diverticulitis before operation was three (range, 1-5). Mean time between the last episode and operation was 46 (range, 2-250) weeks. In our first three years of experience, three cases (18.7 percent) were converted to laparotomy. Reasons for conversion were the necessity for intestinal resection, splenectomy, and a wound of the anterior rectum. The mean operative time was 172 (range, 100-280) minutes. Mean hospital stay was 5.7 (range, 3-12) days. There was no mortality. Postoperative morbidity (2 patients, 12.5 percent) consisted of one pulmonary infection and one splenectomy. Long-term follow-up revealed no recurrence of diverticulitis and one incisional hernia. CONCLUSIONS: In experienced hands, laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized sigmoiditis.

Value of hydrogen peroxide enhancement of three-dimensional endoanal ultrasound in fistula-in-ano.
Buchanan GN, Bartram CI, Williams AB, Halligan S, Cohen CR
Dis Colon Rectum 2005 Jan;48(1):141-7.

PURPOSE: The aim of this prospective study was to compare the accuracy of three-dimensional endoanal ultrasound with that of hydrogen peroxide enhanced three-dimensional endoanal ultrasound in diagnosing recurrent or complex fistula-in-ano. METHODS: Three-dimensional endoanal ultrasound reconstructions were performed before and after hydrogen peroxide enhancement in 19 patients with suspected recurrent or complex fistula-in-ano. Two experienced observers derived a consensus fistula classification after a blinded random review of the data sets. The accuracy of three-dimensional endoanal ultrasound and that of hydrogen peroxide-enhanced three-dimensional endoanal ultrasound were compared with a reference standard derived from surgical findings and magnetic resonance imaging and modified by outcome over a median follow-up of 13 months. RESULTS: Patients had previously undergone a median of three fistula operations. Four had Crohn's disease. There were 21 internal openings and primary tracks in 19 patients: 1 superficial, 1 intersphincteric, 18 transsphincteric, and 1 extrasphincteric. Fourteen patients had 19 secondary tracks. Both techniques detected fistula tracks in 19 of 21 (90 percent) patients. There was no significant difference between three-dimensional endoanal ultrasound and hydrogen peroxide-enhanced three-dimensional endoanal ultrasound in classifying internal openings (19/21 (90 percent) vs. 18/21 (86 percent)), primary tracks (17/21 (81 percent) vs. 15/21 (71 percent)), or secondary tracks (13/19 (68 percent) vs. 12/19 (63 percent)). Where three-dimensional endoanal ultrasound correctly detected an internal opening, gas from hydrogen peroxide enhancement was present in 8 of 18 (44 percent) studies. Similarly, gas made primary tracks more conspicuous in 6 of 19 (32 percent) and secondary tracks in 6 of 13 (46 percent) of those detected. CONCLUSIONS: In recurrent or complex fistula-in-ano, endoanal ultrasound proved more accurate for detecting primary tracks and internal openings than for detecting extensions. Hydrogen peroxide improved conspicuity of some tracks and internal openings and so may be helpful in difficult cases, although no overall diagnostic benefit was demonstrated.

Rectal duplication cyst presenting as perianal sepsis: report of two cases and review of the literature.
Flint R, Strang J, Bissett I, Clark M, Neill M, Parry B
Dis Colon Rectum 2004 Dec;47(12):2208-10.

INTRODUCTION: Recurrent perianal sepsis is a difficult problem to manage in colorectal surgical practice. One cause is rectal duplication cyst, a rare congenital lesion that is easily overlooked. Many cases have associated congenital defects, especially musculoskeletal anomalies, and may provide a clue to the underlying condition. Early diagnosis is important because these cysts do not resolve spontaneously and may undergo malignant change. METHODS: We present two cases of middle-aged females who presented with perianal sepsis secondary to rectal duplication cyst. The first case had numerous surgical procedures for a perianal fistula during a ten-year period. She had associated sacral anomalies consistent with Currarino syndrome. The second case presented with a perineal mass after a bout of perianal inflammation. Both cases had the entire cyst surgically excised. RESULTS: There were no complications postoperatively and no recurrence at follow-up. Histopathology revealed no malignancy in the cyst. CONCLUSIONS: Rectal duplication cyst is a rare cause of recurrent perianal sepsis that should be considered in difficult cases, especially in those with associated musculoskeletal anomalies. Complete surgical excision is the preferred treatment to prevent recurrence and the risk of malignant degeneration.

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