Using preoperative three-dimensional endoanal ultrasound to determine operative procedure in patients with perianal fistulas

AIM

Accurate preoperative identification of perianal fistula tracts and internal openings can facilitate the choice of surgical procedure and may lead to improved healing rates. Our aim was to explore the effectiveness of three-dimensional endoanal ultrasound (3D-EAUS) in determining the type of perianal fistula and planning operative management.

METHOD

This was a cohort longitudinal study. Patients with perianal fistulas from January 2017 to January 2018 who underwent 3D-EAUS and subsequent surgery were included. Intra-operative findings were considered as standard for comparison with clinical examination and 3D-EAUS findings. The primary outcome measure was to evaluate the concordance between 3D-EAUS and intra-operative findings and the secondary outcome measure was healing rates.

RESULTS

Sixty-eight patients with a mean age of 43.1 ± 14.1 years were included. Twenty-eight patients had inter-sphincteric (41.2%) and 40 (14 high and 26 low) trans-sphincteric fistulas (58.8%). 3D-EAUS, clinical examination and intra-operative exploration could predict the location of internal openings in 62/68 (91.2%), 48/68 (70.5%) and 56/68 (82.4%) patients, respectively. Hydrogen peroxide (H₂O₂)-enhanced 3D-EAUS accurately predicted the location of internal openings when compared with 3D-EAUS without H₂O₂ (concordance K = 0.963, P = 0.05). High concordance rates were seen between intra-operative and 3D-EAUS findings on the type of perianal fistula. No significant difference was seen between the suggested surgical treatment based on 3D-EAUS and the eventual surgical treatment (P > 0.05). Study limitations were the small sample size and lack of randomization.

CONCLUSION

3D-EAUS may be considered as a first-line investigation for patients with perianal fistulas because of high concordance with intra-operative assessment and facilitation of surgical planning.

Comparison of the sensitivity and specificity of p16/Ki-67 dual staining and HPV DNA testing of abnormal cervical cytology in the detection of histology proven cervical intraepithelial neoplasia grade 2 and above (CIN 2+)

INTRODUCTION

Human papillomavirus (HPV) testing is used as a means of triaging cervico-vaginal smears with low grade squamous abnormalities or as part of co-testing with cytology. While HPV testing has a high sensitivity, it has a low specificity in detecting cervical intraepithelial neoplasia grade 2 and above (CIN 2+) leading to unnecessary colposcopy referrals. We investigate the accuracy of the p16/Ki-67 dual immunocytochemical stain in determining the presence of CIN 2+ lesions on histology and its potential as a superior biomarker for triage.

METHODS

Liquid based cervico-vaginal cytology specimens with squamous abnormalities and corresponding histology from 97 women with subsequent colposcopy and biopsy were included. The specimens were then subjected to the dual stain and Roche Cobas 4800 multiplex real time PCR HPV DNA testing. The sensitivity and specificity of the dual stain and HPV testing were calculated using CIN 2+ on histology as a reference standard.

RESULTS

The sensitivity and specificity of the dual stain in detecting histology proven CIN 2+ was 93.7% and 76.5% while HPV testing was 85.7% and 14.7% respectively. Of the 44 women with ASCUS or LSIL on cytology, the dual stain also reduced the number of unnecessary colposcopy referrals from 27 to 7 when used as a triage marker compared to HPV testing.

CONCLUSION

p16/Ki-67 dual stain was more sensitive and specific than HPV testing in determining the presence of CIN 2+ on histology. It could triage low grade cervico-vaginal specimens more effectively and potentially help women avoid unnecessary colposcopies. Future studies are needed to further evaluate its role in cervical cancer screening programmes.

Percutaneous tibial nerve stimulation vs sacral nerve stimulation for faecal incontinence: a comparative case-matched study

AIM

The study assessed the initial experience with posterior tibial nerve stimulation (PTNS) for faecal incontinence and compared it with sacral nerve stimulation (SNS) performed in a single centre during the same timespan.

METHOD

A retrospective review of a prospectively collected database was conducted at the colorectal unit, University Hospital, Nantes, France, from May 2009 to December 2010. Seventy-eight patients diagnosed with chronic severe faecal incontinence underwent neurostimulation including PTNS in 21 and SNS in 57. The main outcome measures were faecal incontinence (Wexner score) and quality of life (Fecal Incontinence Quality of Life, FIQL) scores in a short-term follow-up.

RESULTS

No significant differences were observed in patients' characteristics. Of 57 patients having SNS, 18 (32%) failed peripheral nerve evaluation and 39 (68%) received a permanent implant. Two (5%) developed a wound infection. No adverse effects were recorded in the PTNS group. There was no significant difference in the mean Wexner and FIQL scores between patients having PTNS and SNS at 6 (P = 0.39 and 0.09) and 12 months (P = 0.79 and 0.37). A 50% or more improvement in Wexner score was seen at 6 and 12 months in 47% and 30% of PTNS patients and in 50% and 58% of SNS patients with no significant difference between the groups.

CONCLUSION

Posterior tibial nerve stimulation is a valid method of treating faecal incontinence in the short term when conservative treatment has failed. It is easier, simpler, cheaper and less invasive than SNS with a similar short-term outcome.

The magnetic anal sphincter in faecal incontinence: is initial success sustained over time?

AIM

In the short term, implantation of a magnetic anal sphincter (MAS) is a safe and effective treatment for faecal incontinence (FI). In this paper we show that the initial results stand the test of time and patient satisfaction remains high in the medium term.

METHOD

Data on 23 women [median age 64 (35-78) years] implanted with a MAS device between December 2008 and September 2012 were reviewed from a prospective database. Assessment was based on significant improvement of incontinence scores - the Cleveland Clinic Florida Incontinence Severity (CCF-IS) score, Faecal Incontinence Quality of Life (FIQoL) score - and patient satisfaction at 6, 12, 24 and 36 months after surgery.

RESULTS

The device was removed in two patients owing to complications. Median follow-up was 17.6 months. The median preoperative CCF-IS score was 15.2 and fell to 6.9, 7.7, 7.8 and 5.3 at 6, 12, 24 and 36 months, respectively. The median FIQoL score significantly (P < 0.001) improved from 1.97 preoperatively to 3.19, 3.11, 2.92 and 2.93, respectively, at the same time periods. The concordance of the CCF-IS and FIQoL scores was 91%. Sixteen of the 23 patients were satisfied but only 14 would have recommended the MAS to someone else. Lack of improvement was the main reason for dissatisfaction.

CONCLUSION

Good initial results tend to remain stable over time and about two-thirds of patients are satisfied after MAS implantation.

Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation?

AIM

Function, morbidity and recurrence of symptoms after robotic-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for pelvic floor disorders (PFDs) were compared.

METHOD

Forty-four patients operated on for PFD with RVMR were compared with 74 of 144 patients who had had LVMR performed between 2008 and 2011. The groups were matched for age, body mass index, American Society of Anesthesiologists status and previous hysterectomy. The same surgical technique and type of mesh were used. Early postoperative morbidity and function [obstructed defaecation syndrome (ODS), incontinence scores (CCF) and sexual activity] were compared.

RESULTS

Operation time was longer in RVMR compared with LVMR (191 ± 26 vs 163 ± 39 min; P = 0.0002). RVMR showed less blood loss (8 ± 34 vs 42 ± 88 ml; P = 0.012) and fewer early complications (2% vs 11%; P = 0.019). ODS and CCF scores improved in both groups. Patients after RVMR reported a better improvement in digitation, straining and satisfaction after defaecation. There was a statistically significant difference in the postoperative ODS score in favour of RVMR (P = 0.004). Sexually active patients in both groups reported a similar improvement. There was no difference in early recurrence (P = 0.692).

CONCLUSION

Although not a randomized comparison, this study shows that ventral mesh rectopexy performed by the robot was followed by better function then LVMR.

The impact of anorectal malformations on anorectal function and social integration in adulthood: report from a national database

AIM

The impact of anorectal malformation (ARM) on bowel function and social, educational and occupational end-points was investigated in adult patients entered on a national database.

METHOD

Data from a national database of adult patients operated on between 1962 and 1999 for ARM were analysed. The database Malformations Ano-rectales et Pelviennes rares (MAREP) was part of a common information system, CEMARA, on rare congenital disorders. A self-administered questionnaire regarding bowel function, academic qualifications, employment and family status was mailed to patients. The type of ARM, subsequent follow-up and management including surgical interventions were retrospectively retrieved from medical records.

RESULTS

Of 210 adult patients on the registry since 2008, 68 were included in this study. Only three (8.5%) had had regular follow-up. All reported some disturbance in bowel function. The fertility rate of 1.5 children per woman did not differ from the general population.

CONCLUSION

Anorectal malformation ARM often leads to suboptimal bowel function in adulthood. This has an impact on social integration.

Primary multi-drug resistant tuberculous gumma

A 28-year old lady presented with three discrete gummatous lesions on the anterior abdominal wall, one at the site of a previous laparoscopic scar. Skin biopsy showed epitheloid cell granulomas and a pus culture and sensitivity (for AFB) performed, showed growth of M. tuberculosis. The culture-isolate was resistant to all the essential anti-TB drugs. The patient was put on second line anti-TB chemotherapy and the gummas resolved.