Postanal sinus: single or different etiologies?

Experience with five patients who presented with a postanal sinus (PAS), all of which appeared to have a similar etiology at first hand, is reviewed. All patients were female and presented with a perianal fistula located in the midline posterior to the anus between the internal and external sphincter. All patients had a similar history and age at presentation (the 1st decade of life), which increased our assumption of a similar etiology. Further examinations revealed no internal connection to hollow organs or other pelvic structures, proving that the fistula was a sinus in all cases. One patient had a scimitar sacrum. In four cases the sinus was excised transanally, in one through a posterior sagittal approach. All patients had normal anal function postoperatively. Histologic examination was performed in all cases and showed results ranging from various types of epithelium to dermoid and epidermoid cysts, dismissing the theory of a similar etiology. In our opinion, a PAS can be a presenting sign for a variety of retrorectal developmental pathologies and should be differentiated from fistula-in-ano.

Leakage of adjustable gastric bands.

BACKGROUND: Surgery for morbid obesity has increased since the introduction of the adjustable gastric bands. Their advantage is the adjustability of the band, which can be inflated or deflated percutaneously according to weight loss without altering the anatomy of the stomach. We present 5 cases of leakage of the Swedish adjustable gastric band (SAGB) as a result of tearing of the balloon. METHODS: In our series, 29 patients received an SAGB; the remaining 20 received the LapBand. All but 4 procedures were performed laparoscopically. The adjustable gastric band (AGB) was inflated according to passage seen on gastro-esophagogram. According to weight loss or complaints of passage, the gastroesophagogram was repeated, and the AGB was inflated or deflated. RESULTS: No major complications were observed postoperatively. All but 5 patients showed weight loss and restriction of food intake after filling of the AGB. These 5 patients had all received an SAGB. High-pressure filling with contrast medium showed leakage of the SAGB. After removal the SAGB, 4 showed a tear at the site of fixation of the balloon to the band, and 1 showed a puncture of the balloon. The tears most probably occurred as a result of inadequate fixation while the SAGB was positioned around the stomach. CONCLUSION: To our knowledge, this complication has not been described before. The manufacturer of the SAGB has been notified, and consequently the fixation site has been reinforced.

Colour duplex scanning and pulse-generated run-off for assessment of popliteal and cruropedal arteries before peripheral bypass surgery.

BACKGROUND: This prospective pilot study compared the diagnostic accuracy of duplex scanning and pulse-generated run-off (PGR) with intra-arterial digital subtraction angiography (IADSA) for assessment of popliteal, crural and pedal arteries, and explored the reliability of investigation with the combination of duplex scanning and PGR in patients who needed femorodistal reconstruction. METHODS: In 23 limbs, 345 arterial segments were graded independently with duplex scanning and IADSA as normal, stenosed or occluded and compared using weighted kappa analysis. PGR was rated as good, poor or no run-off and compared with pedal arch patency on IADSA. Based on information derived from duplex scanning and PGR a vascular surgeon proposed treatment and the distal anastomosis site for bypass, which was compared with definitive treatment as determined by IADSA. RESULTS: Overall agreement between duplex scanning and IADSA for popliteal and crural arteries was moderate (kappa 0.47, 95 per cent confidence interval (c.i.) 0.39-0.55) with best agreement within the popliteal and proximal tibial arteries. Agreement within pedal arteries was fair (kappa 0.35, 95 per cent c.i. 0.17-0.53). PGR detected good run-off in five of 21 pedal arteries shown to be occluded on IADSA. In 16 of 23 patients treatment based on duplex scanning and PGR was identical to that based on IADSA. Eight of eleven femoropopliteal bypasses were predicted accurately. CONCLUSION: Operative strategy could have been based on investigation by duplex scanning and PGR in a substantial number of patients scheduled for femoropopliteal bypass surgery. Agreement between duplex scanning and IADSA within very distal arterial segments was fair.

Risk of residual rectal mucosa after proctocolectomy and ileal pouch-anal reconstruction with the double-stapling technique. Postoperative endoscopic follow-up study.

PURPOSE: This study was designed to assess the risk of retained rectal mucosa after proctocolectomy and ileal pouch-anal anastomosis with the double-stapling technique. METHODS: A total of 113 patients underwent proctocolectomy with an ileal pouch-anal reconstruction. In 57 patients the anastomosis between pouch and proximal anal canal was performed using the double-stapling technique. In 26 patients the procedure was carried out without a protecting ileostomy. Of the remaining 31 patients with a proximal ileostomy, 15 underwent endoscopy six weeks postoperatively. Circular biopsies were taken just distal from the pouch-anal anastomosis. RESULTS: Histologic examination revealed rectal mucosa in at least one biopsy in 7 of 15 patients. At follow-up (mean 18 months) no (distal) pouchitis was clinically noticed. In one patient with familial polyposis, a few polyps, distal of the anastomosis, had to be endoscopically removed. CONCLUSIONS: Double-stapled ileal pouch-anal anastomosis has a considerable risk of residual rectal mucosa, because of combined linear transection and circular stapling with bilateral dog-ear formation of rectal mucosa. Residual rectal mucosa did not seem to influence clinical results at follow-up.