Endorectal Advancement Flaps for Perianal Fistulae in Crohn's Disease: Careful Patient Selection Leads to Optimal Outcomes.

BACKGROUND: Anorectal fistulae resultant from Crohn's disease (CD) is a clinical challenge. The advent of immune therapy (IT) has altered the way in which fistulae have responded to treatment. Endorectal advancement flap (ERAF) is a surgical procedure that is used to treat complex fistulae. We have employed ERAF as our second stage treatment of choice in this patient population. Our aim was to determine the success of ERAF in treating perianal fistulas in patients with CD in an era of IT. METHODS: Multicenter retrospective review from 2007 to 2017 of all patients with CD and a perianal fistulae who underwent ERAF. RESULTS: Forty-one flaps were performed in 39 patients with perianal CD with an average follow-up of 797 days. There were no significant differences in patient demographics; however, all patients who were diverted at the time of surgery had successful healing. Of patients, 73.2% were on IT at an average of 380 days prior to surgery. The duration of single-agent therapy was associated with better healing rates (p = 0.03). The overall failure rate was 19.5% (n = 8). Six patients underwent secondary techniques for fistulae closure; five were successful. In combination with the patients who did not initially fail, the overall healing rate was 92.6%. CONCLUSIONS: This study demonstrates several factors that may improve fistulae closure for CD patients. Patients who were diverted prior to surgery did not have a fistulae recurrence. Patients who were on IT longer prior to ERAF were more likely to achieve successful closure.

The Effect of a Global Surgery Resident Rotation on Physician Practices Following Residency: The Mount Sinai Experience.

OBJECTIVE: The goal of the study was to evaluate the impact of Mount Sinai's international rotation on physician practices and attitudes following residency. DESIGN: An anonymous, retrospective study was conducted using an email survey. The initial survey was sent out in July 2015 with a second opportunity in September 2015. SETTING: Mount Sinai Hospital, New York City. PARTICIPANTS: All 62 graduates of the Mount Sinai General and Plastic Surgery residencies who participated in the international rotation over the last 10 years. RESULTS: The primary outcome was level of involvement in service medicine with a secondary outcome examining participants views on the value of international rotations during residency. The response rate for the survey was 71% (44/62). Since leaving residency, 53% have been involved in one or more types of service medicine, 59% have been involved in at least one experience practicing medicine in an underserved area and 45% state that their current practice incorporates global surgery or service. 61% report that the rotation encouraged an interest in practicing in an underserved area and 44% (8/18) of those with no prior interest in global health reported that the rotation encouraged an interest. Respondents generally believe global health work could be rewarding (89%), provide opportunity for professional development (77%), and that residency should include global health electives (93%). CONCLUSIONS: Our results suggest that a mandatory global health rotation may encourage an interest in service medicine. Thus, program directors should continue to provide and encourage participation in international rotations during surgical residency.