A novel method for treatment of chronic anal fissure: adipose-derived regenerative cells - a pilot study.

AIM: The purpose of this study was to investigate the safety and feasibility of autologous adipose-derived regenerative cells (ADRC) in the treatment of chronic anal fissure. METHOD: A prospective pilot study was conducted in six patients with chronic anal fissures at the First Surgical Clinic, Clinical Center of Serbia and at the BelPrime Clinic, Belgrade, Serbia. All patients were candidates for surgical treatment. The average duration of symptoms was 24 months. Pain assessment was quantified using a visual analogue scale and bowel continence was assessed using the Wexner incontinence score. Both were assessed before treatment and during each postoperative outpatient visit. Liposuction was performed under local or general anaesthesia. Extraction of ADRC was achieved with a closed automated medical device. The fat and ADRC were injected subcutaneously into the edge of the fissure. The rest of the pellet was infiltrated into the internal anal sphincter. The study has been registered at ClinicalTrials.gov (NCT02628522). RESULTS: Complete healing of the anal fissure and the disappearance of symptoms was achieved in all patients. The average time to complete pain cessation was 33.7 ± 15.0 days. All fissures healed after 3 months and remained healed 12 months after the procedure. There were no complications related to the procedure. CONCLUSION: The application of ADRC may be an alternative to lateral sphincterotomy and a reliable procedure which avoids faecal incontinence.

Factors influencing circumferential resection margin in rectal cancer.

AIM: Abdominoperineal excision (APR) has been associated with higher circumferential resection margin (CRM) involvement and local recurrence rates than extralevator APR for low rectal cancer. This study aimed to evaluate the CRMs in APR and low anterior resection (LAR) specimens and to identify factors influencing CRM involvement. METHOD: All pathological specimens from consecutive patients with rectal cancer who underwent curative resection at the Cleveland Clinic Florida, from January 2000 to July 2010, were reviewed by two pathologists. Demographics, tumour characteristics, operative data, postoperative pathology and Dworak's tumour regression grade were compared between specimens with positive and negative CRMs. RESULTS: One-hundred and fifty-four patients underwent curative APR (n = 65) or LAR (n = 69). Mean tumour size was 3.6 cm, and mean distance from the dentate line was 5.4 cm. Nine (6.8%) patients had a positive CRM (n = 6 APR, n = 3 LAR), which was associated with tumour size > 5.9 cm (P = 0.002), a distance of ≤ 2.6 cm from the dentate line (P = 0.013), microvascular invasion (P = 0.009), perineural invasion (P < 0.001), number of positive lymph nodes (P = 0.046) and incomplete total mesorectal excision (TME) (P < 0.001). APR specimens were three times more likely than LAR specimens to have an incomplete mesorectum (9.8%vs 2.9%, P = 0.322). CONCLUSIONS: Factors associated with a positive CRM were tumour size > 5.9 cm, a distance of ≤ 2.6 cm from the dentate line, incomplete TME, number of positive nodes and microvascular and perineural invasion. The incidence of a positive CRM was not significantly different between LAR and APR (n = 3 LAR and n = 6 APR).

Colorectal anastomotic stricture: is it associated with inadequate colonic mobilization?

BACKGROUND: Anastomotic stricture or stenosis is a well-described complication of intestinal anastomosis. The incidence of stricture after colorectal anastomosis ranges from 0 to 30 %. The aim of this study was to identify possible factors related to postoperative colorectal anastomotic stricture and to indicate reoperative surgery outcomes. METHODS: After institutional review board approval, medical records were reviewed for patients who underwent surgery for colorectal anastomotic stricture at Cleveland Clinic Florida between January 2001 and December 2010. The main outcome measures were demographics, indications for initial surgery, body mass index, comorbidities, previous treatment, level of anastomosis, history of radiotherapy, and operative data for the reoperative surgery. RESULTS: Nineteen patients (15 males) were eligible for the study. Nine patients had a diagnosis of cancer, 7 of whom received radiotherapy. The initial surgeries were low anterior resection (n = 9; 47.4 %), high anterior resection (n = 9; 47.4 %), and sigmoidectomy (n = 1; 5.2 %). Six patients (31.6 %) had anastomotic leak after initial surgery. The majority of the patients (n = 17; 89.5 %) had an intact splenic flexure, inferior mesenteric artery, and inferior mesenteric vein. In all patients, full mobilization of the splenic flexure and high ligation of the mesenteric vessels was performed. Seven patients (36 %) developed postoperative complications. Over a mean follow-up of 24.3 months, there was no recurrence of anastomotic stricture. CONCLUSIONS: An intact splenic flexure and mesenteric vessels were the most prevalent in patients who underwent reoperation at our institution. Full mobilization of the splenic flexure, high ligation of the mesenteric vessels, anastomotic stricture resection, and re-anastomosis can be successfully performed with satisfactory outcomes.