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.

Laparoscopic-assisted bowel resection in pediatric/adolescent inflammatory bowel disease: laparoscopic bowel resection in children.

PURPOSE: The purpose of this study is to discuss indications, technical approach, and morbidity of laparoscopic approaches to major bowel resection in the pediatric/adolescent population with inflammatory bowel disease and familial polyposis. METHODS: Retrospective review of laparoscopic-assisted bowel procedures between May 1991 and January 2002 was performed. Laparoscopic-assisted bowel resection is defined as complete intracorporeal mobilization and devascularization of a segment of colon or rectum. The indications for extracorporeal vs. intracorporeal anastomosis will be discussed. Clinically unstable, septic, or massively bleeding patients were not candidates for this technique. The decision to attempt the laparoscopic approach was based on the experience of the consulting surgeon. There were 31 patients, including 14 females. Five patients had undergone prior surgery. Twenty-nine patients had inflammatory bowel disease, one had familial polyposis, and one had a cavernous hemangioma. We included all pediatric/adolescent patients in our practice undergoing laparoscopic resection. RESULTS: Twenty-nine patients had 33 laparoscopic operations, including proctocolectomy with ileal pouch-anal anastomosis (n = 14), proctocolectomy with ileostomy (n = 3), ileocolectomy with ileocolic anastomosis (n = 13), and small-bowel obstruction (n = 1). Average operating time was 158 (range, 30-400) minutes, with average blood loss of 159 ml. Average wound length was 4.9 cm. The complication rate was 16 percent (n = 5), with one anastomotic leak. The rate of conversion to open operations was 5.8 percent. Liquid diet was begun on Day 3, and the average length of stay was 5.9 days. CONCLUSION: Major laparoscopic bowel surgery can be performed safely in the pediatric/adolescent population, with reasonable operative times, low conversion to open operations, and low morbidity.

Harmonic scalpel hemorrhoidectomy: five hundred consecutive cases.

PURPOSE: The aim of this study was to evaluate the incidence of postoperative complications after Harmonic Scalpels hemorrhoidectomy and to identify any predisposing factors leading to postoperative complications. METHODS: Five hundred consecutive cases of Harmonic Scalpel hemorrhoidectomy were studied in a prospective manner. Postoperative complications were recorded, and any predisposing factors were evaluated. RESULTS: Three hundred fifty-five patients (71 percent) underwent Harmonic Scalpel hemorrhoidectomy alone. One hundred twenty patients (24 percent) underwent additional fissurectomy/sphincterotomy for fissure-in-ano, and 25 patients (5 percent) underwent additional fistulotomy. A total of 24 (4.8 percent) patients experienced some form of postoperative complication. Three patients (0.6 percent) experienced a secondary postoperative hemorrhage requiring reexploration under anesthesia. Two of the three patients were taking postoperative oral Toradol, and both had undergone an "open" hemorrhoidectomy technique. The third patient required suture ligation of multiple bleeding sites on two separate occasions at 7 and 14 days postoperatively. The patient was subsequently diagnosed as having Ehlers-Danlos syndrome. One patient experienced postoperative incontinence to flatus and stool. The patient had large, Grade TV postpartum hemorrhoids and had undergone a three-quadrant closed hemorrhoidectomy. The sphincter mechanism was intact on postoperative ultrasound, and an underlying pudendal neuropathy likely contributed to the sphincter dysfunction. Postoperative urinary retention was noted in 10 (2 percent) patients, postoperative fissure in 5 (1 percent), and abscess/fistula in 4 (0.8 percent). One patient (0.2 percent) required readmission for colonic pseudo-obstruction. CONCLUSION: Harmonic Scalpel hemorrhoidectomy is a safe surgical modality, and postoperative complication rates compare favorably with previously published studies. The combination of an "open" hemorrhoidectomy technique and prolonged oral Toradol administration may result in a higher incidence of postoperative hemorrhage.