Why do we have to review our experience in managing cases with idiopathic fistula-in-ano regularly?

"Why do we have to review our experience in managing idiopathic fistula-in-ano regularly?" In order to answer this apparently simple question, we reviewed our clinical and surgical cases and most important relevant literature to find a rational and scientific answer. It would appear that whatever method you adopt in fistula management, there is a price to pay regarding either rate of recurrence (higher with conservative methods) or impairment of continence (higher with traditional surgery). Since, at the moment, reliable data to identify a treatment as a gold standard in the management of anal fistulas are lacking, the correct approach to this condition must consider all the anatomic and clinicopathological aspects of the disease; this knowledge joined to an eclectic attitude of the surgeon, who should be familiar with different types of treatment, is the only guarantee for a satisfactory treatment. As a conclusion, it is worthwhile to remember that adequate initial treatment significantly reduces recurrence, which, when it occurs, is usually due to failure to recognise the tract and primary opening at the initial operation.

Preoperative radiochemotherapy in t3 operable low rectal cancers: a gold standard?

BACKGROUND: Preoperative chemoradiation followed by total mesorectal excision (TME) has become a standard treatment of preoperatively staged T3 low rectal cancers in many institutions; however, a direct comparison of generalized preoperative versus selective adjuvant chemoradiation has never been assessed in a clinical practice setting. PATIENTS: Over a 4-year period, 80 patients with T3 primary low adenocarcinoma of the rectum, judged operable at preoperative staging, were offered preoperative chemoradiation. Forty-seven patients (Group I) accepted the neoadjuvant treatment and 33 (Group II) preferred immediate surgery and postoperative chemoradiation if indicated. RESULTS: Major postoperative complications occurred in 21% of Group I versus in 11% of Group II (p = 0.3) patients. After a mean follow-up of 92 months, the local recurrence rate was 4 and 9% (p = 0.4), metastasis rate was 30 and 24% (p = 0.5), 5-year survival probability was 0.79 (95% CI = 0.49-0.92) and 0.82 (95% CI = 0.70-1.00) (log-rank test, p = 0.6) for Group I and Group II, respectively. CONCLUSIONS: In T3 operable low rectal cancers, selective postoperative radiochemotherapy yielded similar long-term results regarding recurrence rate and survival as extended preoperative chemoradiation.

Excision of the levator muscles with external sphincter preservation in the treatment of selected low T4 rectal cancers.

PURPOSE: The existence of an anatomic and functional separation between the puborectalis muscle and external anal sphincter permits the performance of an abdominoendoanal excision, instead of an abdominoperineal excision, of the rectum and levator muscles, with preservation of a functioning external sphincter, in selected patients with very low rectal cancer and limited infiltration of the levator muscles. METHODS: Seven patients (4 females; age, 48-69; mean, 60.7 +/- 7.8 years) with low posterior or posterolateral localized rectal cancers with infiltration of the puborectalis muscle (T4) were submitted to preoperative chemoradiation and excision of the rectum with the levator muscles, while the external sphincter and its innervation were preserved. A coloanal anastomosis was performed at the dentate line. RESULTS: At a median follow-up of 58 (range, 42-102) months, 6 patients (86 percent) were alive and disease free. No local recurrence was observed. Anorectal function, at three years from surgery was no worse than that of six patients of the same age and gender who had undergone more conventional coloanal anastomoses with preservation of the levator muscles. CONCLUSION: Selected patients with very low rectal cancers infiltrating the levator muscles (T4) and responding to preoperative chemoradiation therapy can still be treated with an advanced sphincter-sparing procedure, instead of an abdominoperineal excision. Oncologic and functional results seem to be satisfactory.