Is sacral neuromodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence.

INTRODUCTION: Sacral neuromodulation (SNM) was approved by the FDA for the treatment of fecal incontinence (FI) in 2011, and previous industry-sponsored trials have shown excellent clinical outcomes. The purpose of this study is to examine clinical outcomes of patients treated during our initial experience with SNM. METHODS: A prospective database of patients treated with SNM for FI by one of three colorectal surgeons at two separate institutions was maintained starting in 2011. Patients showing ≥50% improvement of weekly incontinent episodes during test stimulation were offered permanent implantation of the SNM device. Disease severity was tracked using the Wexner score. RESULTS: A total of 145 patients received a full system implantation (of 152 who received test stimulation). The median preoperative Wexner score of 14 decreased to 3, 3 months after implantation and persisted to 12 months. At 12 months, 95.2% of patients achieved >50% improvement in Wexner Score and 67.6% achieved >75% improvement. The most common adverse event was infection (3.4%). Three patients (2.1%) required lead revision. CONCLUSIONS: SNM is a safe and effective therapy for the treatment of FI. Postoperative patient surveillance is important, as many patients require programming changes, and some will require a lead revision over time.

Readmission for dehydration or renal failure after ileostomy creation.

BACKGROUND: Ileostomy creation is a commonly performed operation in colorectal surgery; however, many patients develop complications such as dehydration postoperatively. Dehydration is often severe enough to warrant hospital readmission and may result in renal failure. The true incidence of this complication has not been well described. OBJECTIVE: The aim of this study was to identify the rate of hospital readmission secondary to dehydration or renal failure within 30 days of ileostomy creation. DESIGN: Retrospective review of all patients undergoing ileostomy creation from 2007 to 2011 in a single colorectal practice of 4 surgeons was performed. Charts were reviewed to identify patients readmitted for dehydration or renal failure within 30 days of operation. Data were then analyzed to identify predictors of readmission, dehydration, and renal failure. Subset analysis compared patients readmitted with simple dehydration versus patients with renal failure. PATIENTS: Two hundred one patients undergoing colorectal operations that included ileostomy creation within a 4-year period at a single institution for a variety of indications were included. MAIN OUTCOME MEASURES: The primary outcome measured was readmission for dehydration or renal failure. RESULTS: We observed a 17% 30-day readmission rate for dehydration or renal failure following ileostomy creation. Age greater than 50 was identified as an independent predictor of readmission with renal failure, whereas IPAA was predictive of readmission for simple dehydration, but not renal failure. Patients admitted with renal failure had significantly longer hospital stays and median hospital charges after readmission in comparison with patients admitted with simple dehydration. LIMITATIONS: This study was limited by its retrospective nature and its limited sample size. CONCLUSION: Hospital readmission due to dehydration or renal failure following ileostomy creation is common, with age >50 being the strongest predictor for renal failure. Appropriate strategies to decrease dehydration and renal failure following ileostomy creation need to be investigated.

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.

Office evaluation of rectal bleeding.

Rectal bleeding is a common presentation to the colon and rectal surgeon's office. It is important to develop a systematic approach to its evaluation so as not to miss the presence of a malignancy. The possibility of more than one diagnosis contributing to the symptom should always be kept in mind. It may therefore be necessary to pursue the evaluation of the remainder of the colon, even in the presence of an anorectal source, depending on the risk factors in a given patient. In addition to inspection and digital exam, anoscopes and rigid proctosigmoidoscopes or flexible sigmoidoscopes are available to complete the office evaluation.