Self-pulsed Washable Seton during a Modified Hanley Operation for a Deep Horseshoe Fistula

PURPOSE: The modified Hanley technique, which is used for treatment of a deep horseshoe fistula, has reduced damage to the external anal sphincter compared to the classic Hanley technique, but its shortcoming is that it causes inconvenience to the patient due to the fact that a drainage tube must be left in place for a long time. To solve this problem, the authors devised a self-pulsed washable seton and then compared the results of its use to determine its clinical usefulness. METHODS: The subjects of this study were 34 patients who were diagnosed with a deep posterior complex anal fistula and who were operated on by using the modified Hanley technique between January 1999 and December 2004. Twelve patients who were treated with the self-pulsed washable seton were classified as Group A, and 12 patients who were treated by using a conventional loose seton were placed in Group B. These two groups were compared for period of purulent discharge, period of leaving the seton alone, and recurrence rate. RESULTS: The period of purulent discharge was 18.75 days (15~24) for group Aand 29.75 days (24~37) for group B. The period of leaving the seton was 21.58 days (18~29) for group A and 32.58 days (28~39) for group B. The recurrence rate after surgery was 8.3% in group A and 16.7% in group B. CONCLUSIONS: The self-pulsed washable seton devised by the authors shortened the treatment period through more effective wound management, so we propose using it as a new method for treating a deep posterior horseshoe fistula.

The P-pouch: a New Ileal Reservoir Used in Restorative Proctocolectomy

PURPOSE: To evaluate the effectiveness of a P-pouch configuration with a reservoir and recycled segment in restorative proctocolectomy. METHODS: There were 11 patients who underwent the P-pouch procedure. They were compared with healthy eight-control subjects. The P-pouch configuration was constructed using one firing of a 10 cm GIA stapler to form a 12-cm reservoir. Following that, the distal ileum (15+/-0.5 cm) was anastomosed to the proximal portion of the pouch. Pouch function was studied 23.3+/-4.4 months after ileostomy closure. We measured the frequency and amount of stool. The postprandial plasma peptide YY (PYY) response and the scintigraphic studies using 99m-Tc sulfur colloid were used to study transit. RESULTS: In the patient group, daily stool frequency and volume were 5.2+/-0.3 and 423.5+/-23.7 g, respectively. Stool seepage and pouchitis occurred in 45.5 % and 9.1%. In contrast to other pouch procedures, the postprandial increment of plasma PYY was similar the P-pouch patients and healthy controls (P>0.05). The integrated increment of plasma PYY for 180 minutes following meals was also not decreased in 9-pouch patient group compared with the healthy controls (1,050.0+/-127.8 pmol/l vs. 1146.0+/-150.0 pmol/l, P>0.05). Small intestinal transit time for healthy controls and the patient group averaged 89+/-21 and 117+/-12 minutes (P>0.05). The capacity of the ileal pouch was 372+/-22 ml, and the efficiency of ileal reservoir evacuation was 76 %. CONCLUSIONS: The P-pouch is a new and improved simple modification of the well-established J-pouch procedure, constructed using a single firing of a GIA stapler.

A Subtotally Divided End-loop Colostomy for Unresectable Rectal Cancer

PURPOSE: Divided end-loop colostomy is recommended in some cases of unresectable rectal cancer or anal incontinence, because a conventional loop colostomy is difficult to managing due to bulky stoma volume for a long period. In such case of the divided end-loop colostomy, severe inflammation may occur at the stoma site by poor conditions of the patient so that cause to be retracted or detached, and distal loop may be disrupted. To avoid these problems, we designed subtotally divided end-loop colostomy and studied its clinical effectiveness retrospectively. METHODS: About a 3 cm diameter, round skin incision as presumed colostomy size was made at the left lower abdomen, and entered the abdominal cavity by splitting the rectus muscle fibers. The caudal side of colon can be identified by confirming the fusioned taenia at the rectosigmoid colon level. After pulling out the colonic loop, the distal colon far from the lesion was subtotally divided by a GIA staple or manual suture, which cut obliquely 80% or 90% from the antimesenteric side of the distal loop while maintaining the 10% or 20% mesenteric side of the colonic loop. Then an end-loop colostomy is matured with a small fistularization of the distal loop as the undivided mesenteric side of colon. RESULTS: In 8 cases, subtotally divided colonic loop using a GIA staple. But in 9 cases, divided manually because of makedly thickened, edematous colonic wall resulting from prolonged obstruction. There were several mild complications, i.e. transient dermatitis in 5 cases, transient bulky stoma due to edema in 4 cases, mild retraction of stoma in 2 cases, and mild prolapse of stoma in 1 case. There were no major functional abnormalities during the follow-up period. CONCLUSIONS: Although we need to get further clinical experiences, the subtotally divided end-loop colostomy seems to be a useful alternative surgical procedure for unresectable rectal cancer.