Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up.

PURPOSE: Fibrin adhesive has been successfully used to treat fistulas-in-ano, but long-term data have been lacking. We report the results of our 18-month study examining the repair of fistulas-in-ano using autologous and commercial fibrin adhesive. METHODS: A 79-patient, prospective, non-randomized clinical trial was performed in which fibrin adhesive was used to repair fistulas-in-ano. Twenty-six patients were treated with autologous fibrin tissue adhesive made from their own blood, and 53 patients were treated with commercial fibrin sealant. In the operating room the patient underwent an examination under anesthesia, with an attempt to identify the primary and secondary fistula tract openings. The fistula tract was then curetted. Fibrin adhesive was injected into the secondary fistula tract opening until adhesive was seen coming from the primary opening. A petroleum jelly gauze was then applied over both the primary and secondary openings, and the patient was sent home. Follow-up visits occurred one week, one month, three months, and one year later. RESULTS: Fourteen of 26 (54 percent) patients treated with autologous fibrin tissue adhesive made from their own blood had complete closure of their fistulas after a one-year follow-up, whereas 34 of 53 (64 percent) patients treated with commercial fibrin sealant had closure of their fistulas. Most treatment failures occurred within the first 3 months, but late failures were seen as far as 11 months postoperative. CONCLUSIONS: Fibrin tissue adhesive offers a unique mode of managing fistulas-in-ano, which is surgically less invasive, but recurrences up to one year later are being seen. Longer follow-up and further research is recommended for improvement.

Repair of chronic anorectal fistulae using commercial fibrin sealant.

HYPOTHESIS: Commercially produced fibrin sealant can be used to completely close both simple and complex fistulae in ano. METHODS: A 29-patient prospective nonrandomized clinical trial was performed. In the operating room, the patient underwent an examination with anesthesia and the primary and secondary fistula tract openings were attempted to be identified. The fistula tract was curetted and fibrin sealant was injected into the secondary fistula tract opening until fibrin sealant was seen coming from the primary opening. A petroleum jelly gauze was then applied over the secondary opening and the patient was sent home. Follow-up visits were scheduled for 1 week, 1 month, 3 months, and 1 year later. RESULTS: Twenty-nine consecutive patients received fibrin sealant injections for their fistulae in ano, with a mean follow-up of 6 months. Two patients had a history of Crohn disease (regional enteritis) and 2 patients had human immunodeficiency virus infection. Overall, 17 (68%) of 25 patients have had successful closure of their fistula with 4 patients lost to follow-up. Two patients required reinjection with fibrin sealant, and neither of these subsequently had closure. One of the 2 patients with Crohn disease had closure, as well as 1 human immunodeficiency virus-positive patient. In addition, there has been no evidence of incontinence or complications related to the use of fibrin sealant in this procedure. CONCLUSIONS: Initial results in the treatment of chronic anorectal fistulae using commercial fibrin sealant are optimistic, but require further support through longer follow-up data. Fibrin sealant treatment of anorectal fistulae offers a unique mode of management which is safe, simple, and easy for the surgeon to perform. By using fibrin sealant, the patient avoids the risk of fecal incontinence and the discomfort of prolonged wound healing that may be associated with fistulotomy.

Stoma complications: the Cook County Hospital experience.

PURPOSE: A retrospective analysis of enteric stomas performed at Cook County Hospital was undertaken to evaluate stoma complications per stoma type and configuration and operating service. In addition, we attempted to identify factors predictive of increased enteric stoma complications. METHODS: From 1976 to 1995, data cards on 1,616 patients with stomas were compiled by Cook County Hospital enteric stomal therapists. Data card information included age, gender, weight, early and late stoma complications, emergency status, operating service, type and configuration of the stoma, and whether the patient was seen preoperatively by an enteric stomal therapist. Data were then analyzed using a logistic regression model to identify those variables that influenced the rate of complications. RESULTS: There were 553 (34 percent) patients with complications. Among the total complications, 448 (28 percent) occurred early (<1 month postoperative), and 105 (6 percent) occurred late (>1 month). The most common early complications were skin irritation (12 percent), pain associated with poor stoma location (7 percent), and partial necrosis (5 percent). The most common late complications were skin irritation (6 percent), prolapse (2 percent), and stenosis (2 percent). The enteric stoma with the most complications was the loop ileostomy (75 percent). The enteric stoma with the least complications was the end transverse colostomy (6 percent). The general surgery service had the most complications (47 percent), followed by gynecology (44 percent), surgical oncology (37 percent), colorectal (32 percent), pediatric surgery (29 percent), and trauma (25 percent). Age, operating service, enteric stoma type and configuration, and preoperative enteric stomal therapist marking were found to be variables that influenced stoma complications. CONCLUSIONS: Complications from enteric stoma construction are common. Preoperative enteric stoma site marking, especially in older patients, and avoiding the ileostomy, particularly in the loop configuration, can help minimize complications.

Technical manual for manufacturing autologous fibrin tissue adhesive.

PURPOSE: The aim of this article is to provide a concise and simple technical manual for manufacturing autologous fibrin tissue adhesive derived from the precipitation of fibrinogen using a combination of ethanol and freezing for surgery. METHODS: All materials and equipment needed to manufacture ethanol-based autologous fibrin tissue adhesive are listed. In addition, step-by-step instructions are provided to allow for easy and rapid fibrin adhesive production. RESULTS: Ethanol-based autologous fibrin tissue adhesive can be manufactured in under 60 minutes. Furthermore, at our institution the startup cost for manufacturing ethanol-based autologous fibrin tissue adhesive was under $2,500.00. CONCLUSION: Ethanol-based autologous fibrin tissue adhesive is a safe, reliable, and easily manufactured autologous fibrin tissue adhesive that can be made by a trained technician in any blood bank, pharmacy, or surgical laboratory.

Repair of fistulas-in-ano using autologous fibrin tissue adhesive.

PURPOSE: Our goal was to determine if autologous fibrin tissue adhesive derived from the precipitation of fibrinogen using a combination of ethanol and freezing, could be used to completely close both simple and complex fistulas-in-ano. METHODS: A 26-patient pilot study was performed in which 100 ml of a patient's blood was drawn 90 minutes before surgery. Autologous fibrin tissue adhesive was prepared. In the operating room the patient underwent an examination under anesthesia, and the primary and secondary fistula tract openings were attempted to be identified. The fistula tract was curetted, and autologous fibrin tissue adhesive was injected into the secondary fistula tract opening until fibrin glue was seen coming from the primary opening. A petroleum jelly gauze was then applied over the secondary opening, and the patient was sent home. Follow-up visits were scheduled for one week, one month, three months, and one year later. RESULTS: Twenty-six patients received autologous fibrin tissue adhesive fistula injections, with a mean follow-up of 3.5 months. Initial results were encouraging. Twenty-one of 26 patients (81 percent) had successful initial closure of their fistulas. Two of five failures were injected a second time, and one closed, giving an overall successful closure rate of 85 percent (22/26 patients). Of five patients who failed, mean time to failure was 3.8 weeks. In addition, there was no evidence of infection or complications related to the procedure. CONCLUSION: Our initial results are optimistic and require further support through longer follow-up data. Fibrin glue treatment of anorectal fistulas offers a unique mode of management that is safe, simple, and easy for the surgeon to perform. By using autologous fibrin tissue adhesive the patient avoids the risk of anal incontinence and the discomfort of prolonged wound healing which may be associated with fistulotomy.

Giant pseudopolyps presenting as colocolic intussusception in Crohn's colitis.

Bowel obstruction is a well-known complication of Crohn's disease and is usually a result of stricture formation. Intussusception due to giant pseudopolyps is a rare form of bowel obstruction even in Crohn's disease. These giant pseudopolyps rarely regress with medical management alone and often require surgical resection.

Management of recurrent rectal prolapse.

PURPOSE: Many operations have been described for the management of rectal prolapse. Despite an overall recurrence rate of greater than 15 percent, few reviews address how to deal with this problem. This report summarizes our experience with recurrent rectal prolapse and includes suggestions for reoperative management of failed repairs from both abdominal and perineal approaches. PATIENTS AND METHODS: Fourteen patients (3 male) ranging in age from 22 to 92 (mean, 68) years underwent operative correction of recurrent rectal prolapse. Average time from initial operation to recurrence was 14 (range, 6-60) months. Initial operations (before recurrence) were as follows: perineal proctectomy and levatorplasty (10), anal encirclement (2), Delorme's procedure (1), and anterior resection (1). Operative procedures performed for recurrence were as follows: perineal proctectomy and levatorplasty (7), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (2), Delorme's procedure (1), and anal encirclement (1). Average length of follow-up was 50 (range, 9-115) months. RESULTS: No further episodes of complete rectal prolapse were observed during this period. Preoperatively, three patients were noted to be incontinent to the extent that necessitated the use of perineal pads. The reoperative procedures failed to restore fecal continence in any of these three individuals. One patient died in the postoperative period after anal encirclement from an unrelated cause. CONCLUSION: Surgical management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence. Perineal proctectomies can be safely repeated. Resectional procedures may result in an ischemic segment between two anastomoses, unless the surgeon can resect a previous anastomosis in the repeat procedure. Nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed.

Enterostomal complications: are emergently created enterostomas at greater risk?

It is not unusual for surgeons to have to construct a enterostoma during an emergency abdominal operation. The enterostomal complications, often overlooked, can be serious for the patient. There are many factors relating to stoma complications. The purpose of this paper is to determine whether the emergency status of an operation is an independent risk. Over a 19-year period from 1976 to 1995, there were 1758 enterostomas constructed at our institution. Fifty-nine per cent were for emergent situations, defined as any operation performed for peritonitis, obstructions, or massive hemorrhage. The data pertaining to complications was compiled by the enterostomal therapist and prospectively recorded into an institutional database. Complications were characterized as skin problems, parastomal problems (infection, separation), retraction, stenosis, necrosis, prolapse, and herniation. There were 624 (35%) patients with recorded complications. It was not uncommon for a patient to have more than one complication. There were 500 (55%) skin problems, 111 (12%) parastomal problems, 104 (11%) retractions, 33 (4%) stenoses, 112 (12%) necroses, 28 (3%) prolapses, and 19 (3%) enterostomas herniated. Overall, there were 1044 emergently created enterostomas, and we found that 356 (34%) patients had a complication. The most common indications for emergency laparotomies were abdominal gunshot wounds (40%), bowel obstruction (20%), bowel perforation other than by gunshot or stab wound (15%), and diverticulitis (8%). Among the nonemergently created enterostomas (714), there were 268 (37%) with complications (P = 0.015). Our findings suggest that emergently created enterostomas are not at greater risk for complications, except for the ileostomy. Although further analysis of this particular subset must be undertaken, the technical intricacies of an ileostomy, including preoperative marking of the site, might have an important role.

Does preoperative stoma marking and education by the enterostomal therapist affect outcome?

INTRODUCTION: It is generally accepted that preoperative patient education and skin marking for a stoma location are important in avoiding stoma complications. At our institution, enterostomal therapists are available to educate and mark patients before their surgery. However, for various reasons, not all patients who had an elective stoma created, had preoperative skin marking or instructions on stoma care. Our registry of patients provided us with a means of comparing patients who have undergone an elective stoma with (Group I) and without (Group II) preoperative marking and education. METHODS: Our stoma registry consisting of 1,790 patients was retrospectively reviewed from 1978 to 1996 to assess all patients who underwent elective stoma construction. Patients included for review had a total of 593 elective stomas. All patients with stomas are followed by the enterostomal therapists postoperatively and, therefore, were evaluated for both early and late complications. Early complications were defined as any adverse event occurring within 30 days of surgery and late complications as those occurring 30 days after surgery. RESULTS: Our enterostomal therapists preoperatively evaluated 292 of the 593 patients planned for possible stoma creation. This included careful marking of the stoma site by having the patients lie down, sit, and stand and locating a stable flat area on the abdomen, taking into account the belt line and any abnormal skin creases or deformities. Patients were instructed on stoma appearance with a model and given basic stoma care instructions. In Group I, there were 95 (32.5 percent) complications (68 (23.3 percent) occurred early and 27 (9.25 percent) occurred late). There were 301 patients who did not receive preoperative evaluation (Group II). In this second group, 131 (43.5 percent) complications were found, (95 (31.6 percent) occurred early and 36 (12 percent) occurred late). The difference in total number of complications between groups was determined to be statistically significant, with a P value of <0.0075, as was the difference in early complications, with a P value of <0.03. The difference in late complications is not significant, with a P value of <0.34. CONCLUSIONS: These results confirm that preoperative evaluation by an enterostomal therapist, marking of the skin site, and providing patient education reduce adverse outcomes. All elective procedures that may result in stoma formation should, therefore, be assessed and marked preoperatively. Patients, likewise, should be informed and taught to care for their forthcoming stomas preoperatively and postoperatively.

Pull-through procedures performed months to years after permanent proctectomy.

PURPOSE: Patients who have undergone proctectomy without concomitant rectal reconstruction or coloanal anastomosis were not normally considered candidates for re-establishment of anal continuity until a case report published in 1985. With the addition of nine patients, reported herein is a series of ten patients who have undergone delayed pull-through procedures months to years after permanent proctectomy. PATIENTS: Ten patients (including the single case reported in 1985) have undergone delayed pull-through procedures up to 24 years after permanent proctectomy and ostomy formation. Delayed ileal pouch-anal anastomoses were performed in nine patients, and delayed coloanal anastomosis was performed in one patient. There were four males and six females, each of whom had evidence of external sphincter contraction on physical examination. Average age was 33 (range, 24-51) years at the time of reconstruction. Average duration of follow-up is 32 (range, 1-96) months. RESULTS: One patient is awaiting ileostomy closure. Five of nine patients use constipating agents. Two patients are constipated and use enemas to aid in evacuation. None are wearing protective undergarments. One patient had his ileostomy reconstructed eight years after delayed pull-through for uncontrollable diarrhea associated with chemotherapy for multiple myeloma and recently died. Postoperative complications included wound infection (3), enterocutaneous anastomotic stricture requiring anoplasty (2), small bowel obstruction (1), pneumonia (1), presacral abscess (1), and pouchitis (1). CONCLUSIONS: Delayed pull-through procedures performed months to years after permanent proctectomy can be performed in selected patients, with results comparable to rectal reconstruction done at the time of proctectomy.

Blood flow in colon anastomotic stricture formation.

PURPOSE: The influence of both blood flow and anastomotic technique on the development of anastomotic stricture formation was studied using a dog model. METHODS: Fifty-three dogs underwent distal colocolonic anastomosis with either an EEA (U.S. Surgical Corp., Norwalk, CT) circular stapler or a Czerny-Lembert two-layered, handsewn anastomosis. Blood flow was measured by Laser Doppler Velocimetry using the Laserflo BPM2 (Vasamedics Inc., St. Paul, MN). The animals were separated into three blood flow groups: greater than or equal to 62.5 percent of normal blood flow, between 37.5 percent and 62.5 percent of normal blood flow, and less than or equal to 37.5 percent of normal blood flow. Each blood flow group had an anastomosis performed by either stapling or by hand sewing techniques. At six weeks, the anastomoses were opened longitudinally and fixed to determine the anastomotic index (AI). AI is defined as two times the anastomotic circumference over the proximal circumference plus the distal circumference. Blood flow groups and anastomotic technique groups were compared with an interaction variable for the outcome, AI using a two-way analysis of variance. RESULTS: The AI of the stapled anastomoses was found to be significantly higher than handsewn anastomoses (P < 0.006). There was no difference in AI between different blood flow groups and no correlation of observed histologic findings with AI. CONCLUSION: Clinically relevant ischemia does not directly influence stricture formation in either handsewn or stapled distal colonic anastomoses.

Role of the seton in the management of anorectal fistulas.

PURPOSE: To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton. METHODS: A five-year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow-up ranged from 2 to 61 months (mean, 23 months). RESULTS: Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long-term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent). CONCLUSIONS: Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.

Diversion colitis in patients scheduled for colostomy closure.

Despite recent work, diversion colitis remains poorly defined. Thirty-four patients, scheduled for colostomy closure, were prospectively evaluated with flexible sigmoidoscopy for diversion colitis. Biopsies and cultures were obtained if colitis was identified at endoscopy. All biopsy materials and cultures were consistent with inflammation only. The vast majority of patients were in good general health, and their colostomies were constructed as the result of trauma. Eight patients (24 percent) had normal-appearing colons at an average of 16.6 weeks following diversion. Twenty-six patients (76 percent) demonstrated mild to severe colitis at an average of 29.9 weeks following diversion. Three complications occurred in 22 patients after colostomy closure: two wound infections in patients with colitis and one in a patient with a normal colon. We conclude that diversion colitis in an otherwise individual constitutes no increased risk of infection following colostomy closure.

Rectosigmoid stent for obstructing colonic neoplasms.

Attempting proctoscopic placement of a rectosigmoid stent is proposed as a first step in treating obstructing rectosigmoid neoplasms. If stent placement is successful, elective colon resection can be performed following treatment of any coexisting medical problems that would complicate an emergency colon resection and after routine mechanical bowel preparation.

Rodless end-loop stomas. Seven-year experience.

The rodless, end-loop stoma was developed as an alternative to the more traditional loop stoma to minimize patient management problems. A retrospective review of our seven-year experience in 229 patients with end-loop colostomies (135), ileocolostomies (70), and ileostomies (24) is presented. A total of 30 stoma-related complications were observed in 27 stomas, for an overall complication rate of 13.1 percent. The most common complications were skin excoriation secondary to leakage (3.5 percent), retraction (3.5 percent), partial necrosis (2.6 percent), and peristomal sepsis (1.8 percent). Mucocutaneous separation, prolapse, and stenosis were each seen in less than one percent of patients. No cases of stomal herniation, obstruction, or hemorrhage were encountered. Twelve deaths occurred, but none was attributed to stoma-related complications. The rodless, end-loop stoma is a simple and safe procedure with many advantages and a low incidence of complications.

Bilateral gluteus maximus transposition for anal incontinence.

Seven patients (five men and two women) ranging in age from 26 to 65 years (means = 44) underwent bilateral gluteus maximus transposition for complete anal incontinence. The indications for operation were sphincter destruction secondary to multiple fistulotomies (n = 4), bilateral pudendal nerve damage (n = 2), and high imperforate anus (n = 1). The procedure is performed without the use of a diverting colostomy. The inferior portion of the origin of each gluteus maximus is detached from the sacrum and coccyx, bifurcated, and tunneled subcutaneously to encircle the anus. The ends are then sutured together to form two opposing slings of voluntary muscle. Postoperatively, six patients regained continence to solid stool, two to liquid stool as well, and only one patient in this group was able to control flatus. Although resting pressures remained unchanged, voluntary squeeze pressures were restored by this operation. In addition, rectal sensation was markedly improved, which helps make this a worthwhile procedure for properly selected patients.

The role of fistulography in fistula-in-ano. Report of five cases.

A retrospective review of 27 patients undergoing anal fistulography is presented. The etiology of the 27 fistulas studied are as follows: cryptoglandular infection in 18, IBD in 7 (Crohn's 6, CUC 1), iatrogenic in 1, and foreign body perforation in 1. Twenty-six fistulograms revealed either direct communication with the anus or rectum, or abscess cavities/tracts, or both. Two fistulograms revealed no radiographic evidence of fistula (one patient had two fistulograms). In 13 of the 27 patients (48 percent) information obtained from the fistulograms revealed either unexpected pathology (n = 7) or directly altered surgical management (n = 6). We conclude that anal fistulography in properly selected patients may add useful information for the definitive management of fistula-in-ano.

Island flap anoplasty for the treatment of anal stricture and mucosal ectropion.

Twenty patients with benign anal strictures and five patients with mucosal ectropion were treated with island flap anoplasty. U-shaped or diamond-shaped islands of perianal skin were created, without undermining, and advanced into the anal canal to remedy the stricture or site of ectropion. Over a postoperative follow-up period that averaged 19 months, 16 patients judged their clinical results as excellent and 7 as good. There were two failures. In all patients the skin flaps survived, even in the elderly patients. Island flap anoplasty is a simple, effective alternative to other forms of anoplasty such as Y-V advancement or S-plasty.

Prospective study of the effect of safety belts in motor vehicle crashes.

Trauma resulting from motor vehicle crashes (MVCs) is the leading cause of death in persons 1 to 38 years old. The following prospective study was undertaken to assess the effect of safety belts on the types of injuries sustained in MVCs. A total of 1,364 patients from four Chicago-area hospitals were evaluated prospectively during a six-month period. Safety belts reduced the incidence of head, facial, thoracic, abdominal, and extremity injuries sustained in MVCs. Spinal injuries comprised the only group in which safety belt wearers sustained injuries more frequently than safety belt nonwearers. Further research on the different safety belt designs and effects of air bags is needed to reduce the incidence of cervical and lumbar strain in restrained patients.

Traumatic cloaca.

Deep laceration of the perineum after an obstetric injury may result in a cloacal deformity of the anus and vagina, causing complete fecal incontinence. A surgical technique consisting of reconstruction of the perineal body (perineoplasty) with puborectalis interposition and overlapping external sphincteroplasty is described to correct the defect and restore continence. This procedure has been used on 43 patients in a 10-year period with excellent anatomic and physiologic results.