Distalization of perianal fistulas after loose silicone seton drainage is a myth.

BACKGROUND: It is often stated that loose seton drainage results in distal migration of a fistula tract in perianal fistula. The aim of the present study was to assess this distalization of trans- and suprasphincteric perianal fistulas after a silicone seton has been inserted. METHODS: Consecutive patients who underwent loose seton placement for the management of a transsphincteric or suprasphincteric fistula between January 2016 and December 2021 with a pre- and postoperative magnetic resonance imaging (MRI) were included in the present retrospective study. The height of the external anal sphincter (EAS) and the level of penetration of perianal fistula through the EAS or puborectal muscle (PRM) were determined on MRI. Primary outcome was migration of the fistula tract through the EAS and PRM. RESULTS: Thirty-eight patients with perianal fistulas were included. Median height of the EAS was 28 (IQR 25-34) mm before seton placement and 27 (IQR 24-33) mm afterward. Median level of perforation was 32 (IQR 17-40) mm before seton placement and 28 (IQR 17-40) mm afterward (p = 0.37). One fistula (3%) was downgraded from mid to low transsphincteric and was laid open after 14.9 months of loose seton drainage. CONCLUSIONS: No statistically significant distalization of complex fistula tracts after loose silicone seton drainage was found. Some complex fistulas may downgrade to a less complex fistula after long-term seton drainage. However, loose silicone seton drainage should not be offered to patients as a treatment option to downgrade a complex fistula to a simple one or even have the hope to heal it.

Reversal of left-sided colostomy utilizing single-port laparoscopy: single-center consolidation of a new technique.

BACKGROUND: Considerable morbidity (10-14%) and even mortality (4-30%) have been reported after reversal of intestinal continuity following Hartmann's procedure. Feasibility of and advantages in reducing peri- and postoperative morbidity by utilizing single-port techniques through the colostomy site have been suggested before in small case series. The purpose of the present prospective observational study is to evaluate the outcomes of reversal of intestinal continuity using single-port access in a relatively large consecutive cohort. METHODS: All consecutive patients undergoing single-port reversal of left-sided colostomy (SPRLC) between November 2012 and 2018 were included in the present study. Primary outcome was 30-day postoperative complication rate. Secondary outcomes were postoperative length of stay, single-port success rate, and surgical details like duration and conversion rates. RESULTS: Of 85 procedures, 69.4% were without postoperative complications. No postoperative mortality was encountered. Superficial site infection is the most frequent complication and occurred in 22.4%, major complications classified as Clavien-Dindo grade 3 or above in 9.4% and anastomotic leakage in 3.5%. Median length of stay was 3.0 days (1-69), single-port success rate was 64.7%, and 15.3% was converted to an open procedure. CONCLUSION: This study confirms the safety, feasibility, and the advantages of SPRLC. In centers with adequate laparoscopic experienced surgeons, this technique should be considered as a serious and attractive alternative to restore intestinal continuity in patients with left-sided end colostomy, especially in patients after open index surgery. More research must be done in a multicenter setting to evaluate the use and standardization of single-port technique in reversal of intestinal continuity procedures.

Long-term Outcomes After Surgery Involving the Pelvic Floor in Rectal Cancer: Physical Activity, Quality of Life, and Health Status.

PURPOSE: This study has aimed to evaluate the effects of surgery on physical activity (PA), quality of life (QoL), and disease-specific health status, by analyzing the differences between sphincter-preserving surgery (low anterior resection (LAR)) and abdominoperineal resection (APR) among rectal cancer survivors. METHODS: Individuals who were diagnosed with rectal cancer and who underwent an APR or a LAR between 2000 and 2009 were included. The different questionnaires on QoL, disease-specific health status, and physical activity began their surveys in 2010. Differences in QoL, health status, and physical activity were analyzed between the APR group and the LAR group. RESULTS: The study included 905 rectal cancer survivors (LAR, 632; APR, 273). Besides a higher rate of radiotherapy treatment in the APR group (94% vs. 75%, p < 0.001), there were no differences in clinical characteristics or in comorbid conditions between the LAR group and APR group. No significant differences were found in PA level between the patients who had undergone an APR vs. a LAR. Regarding QoL, APR patients did report a worse physical (p = 0.009) and role functioning (p = 0.03), as well as a worse body image (p = 0.001), compared to patients who had undergone a LAR. However, they reported fewer constipation (p = 0.02) and gastrointestinal problems (p = 0.009). Finally, compared to patients who had undergone a LAR with a permanent ostomy, APR patients reported a better body image (p = 0.048) and less stoma-related problems (p = 0.001). CONCLUSIONS: This study showed no differences in PA level among the patients who had undergone an APR versus a LAR. With respect to their QoL, their physical and role functioning seemed to be worse in the APR patients. However, these differences in outcomes resolved when comparing the APR group with patients after a LAR with a permanent ostomy.