Outcome of Modified Park's Technique for Treatment of Complex Anal Fistula.

BACKGROUND: Treatment of complex anal fistula (CAF) can be associated with high rates of recurrence and fecal incontinence (FI). Park suggested drainage of the affected intersphincteric anal gland for treatment of cryptoglandular anal fistula; however, recurrence after this technique was high. We modified the original Park's technique by extending the internal sphincterotomy to ensure adequate drainage of the intersphincteric space. The aim of this study was to evaluate the incidence of recurrence and FI after modified Park's technique in treatment of CAF. METHODS: Adult patients of both genders with CAF were evaluated before undergoing modified Park's technique with Wexner continence score, clinical examination, and endoanal ultrasonography or MRI. Postoperatively, patients were examined every 2 wk until complete wound healing. The continence state was evaluated with Wexner continence score, and quality of life was assessed before surgery and at 6 mo postoperatively by Short Form-36 questionnaire. RESULTS: Thirty-two patients (27 male) of a mean age of 38 y were included. Median follow-up was 12 mo. Two patients (6.25%) experienced recurrence and 5 (15.6%) developed complications. One patient (3.1%) developed new-onset FI postoperatively. Twenty-eight (87.5%) patients were completely satisfied with the procedure. Quality of life showed significant improvement at 6 mo postoperatively. CONCLUSIONS: The modified Park's technique is a promising procedure for the treatment of CAF with low recurrence and FI rates, and improved quality of life.

Long-term results of cholecystectomy for biliary dyskinesia: outcomes and resource utilization.

BACKGROUND: The purpose of this study is to describe a cohort of pediatric patients undergoing cholecystectomy for biliary dyskinesia (BD) and characterize postoperative resource utilization. METHODS: Single-institution, retrospective chart review of pediatric patients after cholecystectomy for BD was done. Patient demographics and clinical characteristics as well as operative details and postoperative interventions were abstracted. Telephone follow-up was performed to identify persistent symptoms, characterize the patient experience, and quantify postoperative resource utilization. RESULTS: Forty-nine patients were included. Twenty-two patients (45%) were seen postoperatively by a gastroenterologist, of which, only 32% were known to the gastroenterologist before surgery. Postoperative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, five endoscopic retrograde cholangiopancreatographies (ERCPs), one endoscopic ultrasound, one magnetic resonance cholangiopancreaticogram, and five colonoscopies. Of the patients with additional diagnostic testing postoperatively, one had mild esophagitis, three had sphincter of Oddi dysfunction, and one was suspected to have inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea, or vomiting at an average of 26 mo after operation. Of note, all patients who underwent postoperative ERCP with sphincterotomy reported symptom relief following this procedure. CONCLUSIONS: Relief of symptoms postoperatively in pediatric patients with BD is inconsistent. Postoperative studies, though numerous, are of low diagnostic yield and generate high costs. These findings suggest that the initial diagnostic criteria and treatment algorithm may require revision to better predict symptom improvement after surgery. Improvement seen after ERCP/sphincterotomy is anecdotal but appears to merit further investigation.