Fistula-tract Laser Closure (FiLaC™): long-term results and new operative strategies.

BACKGROUND: Fistula-tract Laser Closure (FiLaC™) is a sphincter-saving technique for the treatment of anal fistulas that has been shown to be successful in the short and middle term. However, the long-term success rate is unknown. This study aimed to report long-term results in performing FiLaC™. METHODS: This study was performed as a retrospective observational study. Forty-five patients who underwent FiLaC™ between July 2010 and May 2014 were evaluated. In all cases, FiLaC™ was performed with a diode laser at a wavelength of 1470 nm by means of a radial fiber. Patients and fistula characteristics, previous treatments, healing rates, failures and postoperative incontinence were reviewed. RESULTS: Median follow-up time was 30 months (range 6-46 months). Thirty-five patients (78%) had a history of previous surgery for their fistulas. Primary healing was observed in 32 patients (71.1%), and the median healing time was 5 weeks (range 3-8 weeks). Eleven of the 13 failures (85%) were early failures (persistent symptoms). No patient reported postoperative incontinence. The best healing rate was observed in patients who had been previously treated with loose seton (19/24, 79%). CONCLUSIONS: Long-term follow-up after FiLaC™ seems to confirm the favorable short-term success rates reported for this procedure. Although sealing of chronic anal fistulas may be obtained with FiLaC™ in a single treatment, our current strategy consists of placing a loose seton into the fistula tract a few weeks prior to laser treatment. Seton treatment facilitates the following laser procedure and seems to have favorable effects on healing.

[Giant mucocele of appendix. Case report]. / Mucocele appendicolare gigante. Caso clinico.

Appendiceal mucocele is an uncommon disorder caused by accumulation of mucus within the appendiceal lumen. Mucoceles represent a heterogeneous group comprising various histopathologic lesions including mucosal hyperplasia, cystoadenomas, and cystoadenocarcinomas and prognosis is related to these subtypes. The most common symptom is pain or a palpable mass in the right lower quadrant on physical examination. The preoperative diagnosis is performed with abdominal U.S. and confirmed with CT scan; typical CT scan image is a capsulated cystic mass with calcification of the wall while U.S. pattern shows cystic lesion with the onion skin sign considered a specific sonographic marker for appendiceal mucocele. In conclusion a cystic mass sonographically detected with onion skin sign, in the presence of normal female reproductive organs, suggest the diagnosis of appendiceal mucocele.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis.

BACKGROUND: The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging. METHODS: We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD. RESULTS: Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality. CONCLUSION: We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

A critical appraisal of pathogenesis and morbidity of surgical treatment of chronic anal fissure.

Preoperative and postoperative manometric findings and the results of lateral internal sphincterotomy were analyzed in 44 consecutive patients affected with chronic anal fissure. Preoperatively, resting anal pressure was increased in 32 patients. At one month postoperatively, 23 patients showed normal pressures, whereas 14 were still hypertonic and seven, hypotonic. Only three patients still had a weak sphincter six months postoperatively. The overall morbidity rate was 31.8 percent. Minor complications occurred in 11 patients. Major complications affected three patients. Overall, impaired continence was recorded in eight patients, although only two complained of persistent, albeit lesser, defects of continence not requiring the use of pads. Nonoperative treatment should be reserved for few selected patients with recent, acute fissures. As for chronic and fissures, compared with other operative or nonoperative modalities of treatment, lateral internal sphincterotomy is a highly successful procedure and its minimal morbidity is well accepted by the patient.

Impact of computed tomography vs. intrarectal ultrasound on the diagnosis, resectability, and prognosis of locally recurrent rectal cancer.

The use of modern techniques of imaging in the postoperative follow-up is reported to allow an earlier diagnosis of local recurrence in patients operated on with anterior resection for rectal cancer and, consequently, to allow a higher percentage of local recurrence resection to be performed. Although intrarectal ultrasound (IU) has proved highly reliable in preoperative staging, its value in relapse detection has been investigated only in retrospective studies and rarely compared with that of computed tomography (CT). The present prospective study aims at evaluating the role of IU vs. CT in the diagnosis of local recurrence and at verifying whether an earlier diagnosis and a higher resectability rate of recurrence result in an acceptable long-term survival. Thirty-seven patients who had undergone low and ultralow anterior resection for rectal cancer (anastomosis within 10 cm of the anal verge) were investigated prospectively. All the patients have been followed up by IU and CT at predetermined intervals. Six local recurrences were detected. CT correctly identified all the local recurrences (sensitivity = 100 percent, specificity = 93 percent, and accuracy = 94.5 percent); IU correctly identified only four of six local recurrences (sensitivity = 66.6 percent, specificity = 93 percent, and accuracy = 89 percent). Four patients with local recurrence underwent surgical treatment (resectability rate = 66.6 percent). Abdominoperineal resection in three patients and Hartmann's procedure in one patient were performed. In the other two patients, extensive metastatic liver involvements contraindicated surgery. All the resected patients were alive after one year; two of them are disease free, and the other two experienced recurrent disease. In conclusion, CT seems to have a higher sensitivity and accuracy in relapse detection. The increase in the local recurrence resectability rate does not result in a significant improvement in long-term survival. However, the good quality of life justifies the high cost of an intensive follow-up and a more aggressive surgical approach.