Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases.

PURPOSE: The constant presence of a narrow subcutaneous tract extending caudad to chronic fissures-in-ano is reported. The efficacy of surgically unroofing this tract (subcutaneous fissurotomy) without sphincterotomy was evaluated. METHODS: By using a narrow-gauge, hooked probe, a constant, midline subcutaneous tract was identified extending from the caudad aspect of chronic anal fissures. These tracts are present within the sentinel tag, when present, and extend up to 1 cm caudad to the fissure in the subcutaneous plane. A proximal connection with the dentate line in the submucous plane also was identified. Surgically unroofing the tract (subcutaneous fissurotomy) resulted in significant widening of the distal anal canal, rendering internal sphincterotomy unnecessary. A 32-month prospective evaluation of this new technique was performed. Inclusion criteria included patients with chronic anal fissures that had failed conservative therapy, including topical agents. In each case, the tract was identified and surgically laid open along its entire length. No internal sphincterotomy was performed in any patient. Postoperatively, patients were instructed to apply topical 10 percent metronidazole t.i.d. The need for repeat surgery and/or subsequent internal sphincterotomy was recorded. RESULTS: A total of 109 patients were enrolled during the study period. Median follow-up was 12 months. During the study period, two patients (1.8 percent) required repeat surgery for persistent symptoms at 3 and 12 months postoperatively. No change in continence was reported in any patient. CONCLUSIONS: Laying open the subcutaneous tract has a very high success rate and a low incidence of repeat surgery. This finding introduces a new debate relating to the etiology of fissure-in-ano and makes routine internal sphincterotomy unnecessary.

Combined colonoscopy and three-quadrant hemorrhoidal ligation: 500 consecutive cases.

PURPOSE: This study was designed to evaluate the safety and efficacy of combining outpatient colonoscopy with simultaneous three-quadrant hemorrhoidal ligation in patients with symptomatic internal hemorrhoidal disease. METHODS: A four-year analysis of patients undergoing combined colonoscopy and synchronous three-quadrant hemorrhoidal ligation was performed. Indications for the procedure were patients with symptomatic internal hemorrhoids who had failed conservative management and who also required colonoscopy. Conventional colonoscopy was performed under moderate sedation, immediately followed by synchronous three-quadrant hemorrhoidal ligation, using a TriView anoscope and Short-Shot hemorrhoidal ligator. Patients undergoing this procedure were entered in a computer database, and outcomes were tracked. Patients requiring repeat ligation, surgical intervention, or readmission within 30 days were identified and further analyzed. RESULTS: Five hundred patients underwent colonoscopy with simultaneous three-quadrant internal hemorrhoid ligation during the study period. Four hundred sixty-seven patients (93.4 percent) had complete resolution of their symptoms and required no further treatment. Thirty-three patients (6.6 percent) required repeat ligation, and 11 (2.2 percent) required completion surgical hemorrhoidectomy for persistent symptoms. Fifty-two patients (10.4 percent) required incidental biopsy/polypectomy during the colonoscopy. Two incidental colon carcinomas were identified, and ligation was deferred. No patients required admission for bleeding after the procedure. There were no cases of pelvic sepsis, and no patients required emergent surgical intervention. CONCLUSIONS: Combining colonoscopy with three-quadrant hemorrhoidal ligation is a safe and effective method of treating symptomatic internal hemorrhoids. The procedure is convenient for both physician and patient and makes more efficient use of time and resources.

Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up.

PURPOSE: The long-term efficacy of Surgisis anal fistula plug in closure of cryptoglandular anorectal fistulas was studied. METHODS: Patients with high cryptoglandular anorectal fistulas were prospectively studied. Additional variables recorded were: number of fistula tracts, and presence of setons. Under general anesthesia and in prone jackknife position, patients underwent irrigation of the fistula tract by using hydrogen peroxide. Each primary opening was occluded by using a Surgisis anal fistula plug, which was securely sutured in place at the primary opening and tacked to the periphery of the secondary opening. RESULTS: Forty-six patients were prospectively enrolled during a two-year period. Follow-up was six months to two years (median, 12 months). At final follow-up, all fistula tracts had been successfully closed in 38 patients, for an overall success rate of 83 percent. Seven patients had multiple tracts, for a total of 55 fistula tracts in the series. Of the 55 individual tracts, 47 (85 percent) were closed at final follow-up. Patients with one primary opening were most likely to have successful closure by using the anal fistula plug, although this was not significant. Successful closure was not correlated with the presence of setons. CONCLUSIONS: Long-term closure of cryptoglandular anorectal fistula tracts using Surgisis anal fistula plug is safe and successful in 83 percent of patients and 85 percent of tracts.

Efficacy of anal fistula plug in closure of Crohn's anorectal fistulas.

PURPOSE: The efficacy of Surgisis anal fistula plug in closure of Crohn's anorectal fistula was studied. METHODS: Patients with Crohn's anorectal fistulas were prospectively studied. Diagnosis was made by histologic, radiographic, or endoscopic criteria. Variables recorded were: number of fistula tracts (primary openings), presence of setons, and current antitumor necrosis factor therapy. Under general anesthesia and in prone jackknife position, patients underwent irrigation of the fistula tract by using hydrogen peroxide. Each primary opening was occluded by using a Surgisis anal fistula plug. Superficial tracts amenable to fistulotomy were excluded. RESULTS: Twenty consecutive patients were prospectively enrolled, comprising a total of 36 fistula tracts. At final follow-up, all fistula tracts had been successfully closed in 16 of 20 patients, for an overall success rate of 80 percent. Thirty of 36 individual fistula tracts (83 percent) were closed at final follow-up. Patients with single fistulas (with 1 primary opening) were most likely to have successful closure using the anal fistula plug. Successful closure was not correlated with the presence of setons or antitumor necrosis factor therapy. CONCLUSIONS: Closure of Crohn's anorectal fistula tracts using Surgisis anal fistula plug is safe and successful in 80 percent of patients and 83 percent of fistula tracts. Closure rates were higher with single tracts than complex fistulas with multiple primary openings.

Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas.

PURPOSE: Long-term closure rates of anorectal fistulas using fibrin glue have been disappointing, possibly because of the liquid consistency of the glue. A suturable bioprosthetic plug (Surgisis, Cook Surgical, Inc.) was fashioned to close the primary opening of fistula tracts. A prospective cohort study was performed to compare fibrin glue vs. the anal fistula plug. METHODS: Patients with high transsphincteric fistulas, or deeper, were prospectively enrolled. Patients with Crohn's disease or superficial fistulas were excluded. Age, gender, number and type of fistula tracts, and previous fistula surgeries were compared between groups. Under general anesthesia and in prone jackknife position, the tract was irrigated with hydrogen peroxide. Fistula tracts were occluded by fibrin glue vs. closure of the primary opening using a Surgisis anal fistula plug. RESULTS: Twenty-five patients were prospectively enrolled. Ten patients underwent fibrin glue closure, and 15 used a fistula plug. Patient's age, gender, fistula tract characteristics, and number of previous closure attempts was similar in both groups. In the fibrin glue group, six patients (60 percent) had persistence of one or more fistulas at three months, compared with two patients (13 percent) in the plug group (P < 0.05, Fisher exact test). CONCLUSIONS: Closure of the primary opening of a fistula tract using a suturable biologic anal fistula plug is an effective method of treating anorectal fistulas. The method seems to be more reliable than fibrin glue closure. The greater efficacy of the fistula plug may be the result of the ability to suture the plug in the primary opening, therefore, closing the primary opening more effectively. Further prospective, long-term studies are warranted.

Multiple hemorrhoidal ligation: a prospective, randomized trial evaluating a new technique.

PURPOSE: A modified anoscope was developed, with lateral apertures at the left lateral, right anterior, and right posterior quadrants, to enable synchronous exposure and ligation of all three internal hemorrhoids. Results were compared with those for conventional multiple ligation. METHODS: Postligation pain, complications, and outcomes were compared between synchronous ligation with the new anoscope (synchronous group) and three-quadrant ligation with a conventional anoscope with similar overall dimensions (conventional group). RESULTS: Twenty-five patients were prospectively randomized to each group. Postligation pain and analgesic requirements were recorded up to 28 days, and postligation complications and outcomes were evaluated for a minimum of 6 months. Narcotic requirements were lower in the synchronous group, but this difference did not achieve statistical significance (P > 0.05, Student's t-test). Secondary hemorrhage occurred in 1 patient (4 percent) in the conventional group but resolved spontaneously. The synchronous group experienced significantly less pain during the ligation procedure and for 2 days afterward (P < 0.01, Wilcoxon's test). External hemorrhoidal thrombosis developed in 4 percent of the synchronous group and 12 percent of conventionally treated patients, all of whom responded to conservative treatment. Repeat ligation was required less often in the synchronous group (16 percent) than with conventional ligation (28 percent). Surgery (completion hemorrhoidectomy for external thrombosis) was necessary in one patient (4 percent) in each group. Anal stenosis developed in one patient in the synchronous group. CONCLUSION: The new anoscope provides improved exposure of all three internal hemorrhoids and permits optimal placement of the rubber bands; this may account for the decreased postligation pain and lower repeat ligation rates. Synchronous hemorrhoidal ligation is a less painful method of multiple hemorrhoidal ligation and may improve outcomes compared with conventional multiple ligation.

Harmonic scalpel hemorrhoidectomy: five hundred consecutive cases.

PURPOSE: The aim of this study was to evaluate the incidence of postoperative complications after Harmonic Scalpels hemorrhoidectomy and to identify any predisposing factors leading to postoperative complications. METHODS: Five hundred consecutive cases of Harmonic Scalpel hemorrhoidectomy were studied in a prospective manner. Postoperative complications were recorded, and any predisposing factors were evaluated. RESULTS: Three hundred fifty-five patients (71 percent) underwent Harmonic Scalpel hemorrhoidectomy alone. One hundred twenty patients (24 percent) underwent additional fissurectomy/sphincterotomy for fissure-in-ano, and 25 patients (5 percent) underwent additional fistulotomy. A total of 24 (4.8 percent) patients experienced some form of postoperative complication. Three patients (0.6 percent) experienced a secondary postoperative hemorrhage requiring reexploration under anesthesia. Two of the three patients were taking postoperative oral Toradol, and both had undergone an "open" hemorrhoidectomy technique. The third patient required suture ligation of multiple bleeding sites on two separate occasions at 7 and 14 days postoperatively. The patient was subsequently diagnosed as having Ehlers-Danlos syndrome. One patient experienced postoperative incontinence to flatus and stool. The patient had large, Grade TV postpartum hemorrhoids and had undergone a three-quadrant closed hemorrhoidectomy. The sphincter mechanism was intact on postoperative ultrasound, and an underlying pudendal neuropathy likely contributed to the sphincter dysfunction. Postoperative urinary retention was noted in 10 (2 percent) patients, postoperative fissure in 5 (1 percent), and abscess/fistula in 4 (0.8 percent). One patient (0.2 percent) required readmission for colonic pseudo-obstruction. CONCLUSION: Harmonic Scalpel hemorrhoidectomy is a safe surgical modality, and postoperative complication rates compare favorably with previously published studies. The combination of an "open" hemorrhoidectomy technique and prolonged oral Toradol administration may result in a higher incidence of postoperative hemorrhage.