Video-assisted anal fistula treatment: a new concept of treating anal fistulas.

BACKGROUND: The surgical treatment of complex anal fistulas is very challenging because of the incidence of incontinence and recurrence after traditional approaches. Video-assisted anal fistula treatment is a novel endoscopic sphincter-saving technique. OBJECTIVE: The aim of this article is to evaluate the results of treating complex anal fistulas from the inside and to focus on the rationale and the advantages of this innovative approach. DESIGN: This is a retrospective observational study. SETTINGS: The study was conducted at a tertiary care public hospital in Italy. PATIENTS: From February 2006 to February 2012, video-assisted anal fistula treatment was performed on 203 patients (124 men and 79 women; median age, 42 years; range, 21-77 years) who had complex anal fistulas. One hundred forty-nine had undergone previous anal fistula surgery. INTERVENTIONS: Video-assisted anal fistula treatment has 2 phases: diagnostic and operative. The fistuloscope is introduced through the external opening to identify the main tract, possible secondary tracts or abscess cavities, and the internal opening. With the use of an electrode, the fistula and its branches are destroyed under direct vision and cleaned. The internal opening is closed by a stapler or a flap. Half a milliliter of synthetic cyanoacrylate is used for suture reinforcement. MAIN OUTCOME MEASURES: Successful healing of the fistula was assessed with clinical evaluation. Continence was evaluated by using patient self-reports of the presence/absence of postdefecation soiling. RESULTS: Follow-up was at 2, 4, 6, 12, and 24 months. The 6-month cumulative probability of freedom from fistula estimated according to a Kaplan-Meier analysis is 70% (95%CI, 64%-76%). No major complications occurred. No patients reported a reduction in their postoperative continence score. LIMITATIONS: The limitations of this study included potential single-institution bias, lack of anorectal manometry, and potential selection bias. CONCLUSIONS: Video-assisted anal fistula treatment is effective and safe for the treatment of fistula-in-ano.

Variable activation of phosphoinositide 3-kinase influences the response of liver grafts to ischemic preconditioning.

BACKGROUND/AIMS: The efficacy of ischemic preconditioning (IPC) in preventing reperfusion injury in human liver transplants is still questioned. Phosphoinositide-3-kinase (PI3K) is essential for IPC development in rodent livers. This work investigates whether PI3K-dependent signals might account for the inconsistent responses to IPC of transplanted human livers. METHODS: Forty livers from deceased donors were randomized to receive or not IPC before recovery. PI3K activation was evaluated in biopsies obtained immediately before IPC and 2 h after reperfusion by measuring the phosphorylation of the PI3K downstream kinase PKB/Akt and the levels of the PI3K antagonist phosphatase tensin-homologue deleted from chromosome 10 (PTEN). RESULTS: IPC increased PKB/Akt phosphorylation (p = 0.01) and decreased PTEN levels (p = 0.03) in grafts, but did not significantly ameliorate post-transplant reperfusion injury. By calculating T(2h)/T(0) PKB/Akt phosphorylation ratios, 10/19 (53%) of the preconditioned grafts had ratios above the control threshold (IPC-responsive), while the remaining nine grafts showed ratios comparable to controls (IPC-non-responsive). T(2h)/T(0) PTEN ratios were also decreased (p < or = 0.03) only in IPC-responsive grafts. The patients receiving IPC-responsive organs had ameliorated (p < or = 0.05) post-transplant aminotransferase and bilirubin levels, while prothrombin activity was unchanged. CONCLUSIONS: Impaired PI3K signaling might account for the variability in the responses to IPC of human grafts from deceased donors.