TP10.2.8Adaptation in providing renal access surgery service in response to covid-19 pandemic- a single centre experience

Aim Evaluate impact of Covid-19 pandemic on renal access surgery and changes in practice towards counteracting limitations to provide safe and effective peritoneal and haemodialysis. Methods Retrospective review of procedures for dialysis in ESRD patients from institutional databases in a single centre was carried out. Patients undergoing peritoneal catheter insertions (PD) or AV fistula formation (HD) between March 2020 and October 2020 were compared with similar period in 2019. Demographic, procedure and postoperative outcome data was collected. Results Between March and October 2019, 143 combined PD and HD procedures were performed compared to 98 in the same time period in 2020. The mean age of patients was 65 ± 15 years and 62 ± 12 years, respectively. In 2020, 26 patients had PD catheter insertion and 22 patients in 2019. 18% of these were performed laparoscopically in 2019 compared to 33% in 2020. The same day discharge rate increased to 34% from 22%. Patients having complex fistula procedures including basilic vein transpositions and grafts requiring overnight stay dropped from 83% patients (n = 23) to 71% (n = 7) in 2020. In 2019, 80% (n = 49) patients had radio-cephalic fistula performed as same day procedure increasing to 98% (n = 22) in 2020. Day-surgery unit utilisation increased from 55% to 71%. Same day discharge rate increased from 53% to 66%. There were no readmissions. Conclusions Adaptations in terms of increased support for same day surgery even for complex renal access procedures has improved service. A greater proportion of renal access service can be same day procedures avoiding inpatient stay.

Outcome of fecal incontinence in the two-staged seton fistulotomy for complex fistula in ANO.

Objective: To determine the frequency of fecal incontinence in the two-staged Seton fistulotomy in complex fistula in ano. Study Design: Prospective Cohort study. Setting: Surgical Out-patient Department at Shaikh Zayed Hospital Lahore. Period: September 2015 till March 2016. Material & Methods: After ethical review board approval, data was collected from 100 patients who fulfilled the inclusion criteria. All the procedures were conducted in the lithotomy position, under spinal or general anesthesia. A rigid sigmoidoscopy and proctoscopy was done prior to intervention. Fistula tract was marked using hydrogen peroxide (H202) for the identification of the internal opening. The external opening was gently probed using a standard 3 mm blunt-tipped probe till the internal opening was reached. The portion of the track outside the sphincter mechanism and any lateral tracts were laid open. A feeding tube of size 5 French was loosely tied around the remaining muscular portion of the sphincter complex. The seton was left in place for six weeks followed by secondary fistulotomy. Patients were evaluated for incontinence one month after the second procedure. Results: In our study, mean age was calculated as 47.38+10.96 years, 73%(n=73) were male and 27%(n=27) were females, frequency of fecal incontinence in the two-staged Seton fistulotomy in complex fistula in ano was recorded in 17%(n=17). Conclusion: The frequency of fecal incontinence in the two-staged seton fistulotomy for complex fistula in ano was acceptable in our study population and in tandem with literature. The procedure may be a suitable alternative to loose-seton placement alone.

SPHINCTER CUTTING AND PRESERVING SURGERIES FOR COMPLEX FISTULA IN ANO: A COMPARATIVE STUDY AT A TERTIARY CARE CENTRE IN NORTH INDIA

INTRODUCTION: Anal stula represents an important aspect of colorectal practice, being a distressing condition for the patient and sometimes a challenge for the surgeon. Successful surgical management of anal stulas requires accurate preoperative assessment of the course of the primary stulous tract and the site of any secondary extension or abscess. Fistula-in-ano has various types of clinical presentations. With time newer techniques have also evolved. Here we comparing the various treating modalities by classifying them as sphincter preserving and sphincter cutting surgeries. AIMS AND OBJECTIVES : To compare the outcome, duration of wound healing, recurrence rate, and complications after sphincter preserving and sphincter cutting surgeries. MATERIAL AND METHODS: A total 100 patients were taken up for the study after ethical clearance and proper informed consent. Group A (n=50) patients were selected for sphincter preserving surgeries (VAAFT+FILAC+LIFT, VAAFT+FILAC, LIFT). Group B (n=50) patients were taken up for sphincter cutting procedures (stulectomy and stulotomy). Simple fistulas, and those associated with tuberculosis, IBD, carcinomas, or with perianal injury were excluded from the study. Rectovaginal and anovaginal stulas, patients with history of incontinence, or anal sphincter impairment were also excluded. RESULTS: 66% patients were males and 34% were females. (1.94:1). Mean age of patients was 41.01+12.35 between 20-70 years. Transphincteric stula was the most common type (61%, n=61) and perianal discharge was the most common presentation. (100%, n=100). Primary healing rate at 3 months in sphincter preserving surgeries was 84%, and 66% in cutting surgeries (p<0.05). Recurrence (p<0.05) was st more in cutting surgeries. Incontinence at 1 week (p<0.05) and hospital stay (p<0.05), were also more after cutting surgeries. However, there was no statistically signicant difference in the mean healing time and pain by VAS score at 48 hours. CONCLUSIONS: Sphincter preserving surgeries for complex stula in ano are better in terms of less recovery time and better healing rate, less chances of incontinence, recurrence, compared to sphincter cutting surgeries. With the advent of more sphincter sparing techniques the percentage of patients undergoing sphincter cutting techniques should continue to decrease over time.

Management of of complex fistula-in-ano by a IFTAK technique - case report

Ksharsutra is a Medicated seton which is made by coating the Barbour thread with 21 coatings of Kshara i.e. an herbal alkaline powder, turmeric and latex of Euphorbia nerrifolia. Ksharsutra application is a minimal invasive well established procedure in management of fistula-in-ano. Research on Ksharsutra started since 1968 and it is being used till date with high success rate. In this case report the patient was asymptomatic before 15 years but then a boil developed at perianal region which spontaneously bursted and pus discharge was seen from the boil. Patient was diagnosed with Grade 5 St. James’s university hospital classification of perianal fistulae. This was a case of high anal horse shoe fistula. In this case Fistulectomy or Fistulotomy would cause incontinence. So in this case the Ksharsutra was used but with a modification of classical technique called as IFTAK (Interception of fistulous track with application of Ksharsutra) technique. In which a window was created at 6o’ clock and intersphincteric tract was identified and in that tract Ksharsutra was placed. This technique cures such types of complex Fistula in ano with minimal tissue damage and duration of healing is also reduced.

Outcome of Seton in the Management of Complex Fistula in Ano in a Tertiary Care Center in Bangladesh

Background: The management of high and complex anal fistulas remain a therapeutic challenge as it is often associated with recurrence and anal incontinence. The oldest and theoretically the simplest technique is to use a seton. The aim of this study is to find out the outcome of seton in the treatment of complex fistula in ano. Materials and methods: This cross-sectional study was done in surgical units of ShSMCH and colorectal surgery units of BSMMU from September 2014 to August 2015. Fifty patients with high anal fistula having internal opening above dentate line and with multiple fistulas tract were included by purposive sampling. Patients with low anal fistula, fistula in ano associated with Crohn’s disease, active abdominal tuberculosis, carcinoma of rectum, previous radiation therapy, with recurrent fistula in ano and in whom the internal opening could not be located were excluded. After initial evaluation, the fistula tract and opening were located. The skin and anoderm overlying the fistulous tract were incised. This double-strand seton was then tied over itself on the sphincter without excessive tension. The long end of each suture was tapped to the patient’s medial thigh. Postoperatively warm sitz bath after each bowel movement was advised. The patients were informed in detail about the presence of seton prosthesis and they were warned about the possible serous discharge that would continue until the seton dropped, and the wound healed. Data were recorded on the predesigned questionnaire and analyzed using SPSS version 16. Results: Among 50 cases mean age was 41 years, M: F was 4.5:1. Discharge from perianal sinus, pain, swelling and itching were common clinical presentation. All of the patients were discharged on the third postoperative day. None required readmission or needed narcotic analgesics after discharge. The average time for the seton to cut through the sphincter was 1 to 3 months. 28% had complete healing at 1 month and 66% at 3 months postoperatively. Flatus Incontinence was noted 16% cases followed by recurrence (6%), liquid stool incontinence (4%) and postoperative anal stricture was (2%) of cases. Conclusion: This study found that the seton is a safe and low morbidity option for the treatment of high and complex fistula-in-ano, having higher healing rates, with good quality of life. It can therefore be recommended as the standard treatment for complex fistula-in-ano. J Shaheed Suhrawardy Med Coll, December 2020, Vol.12(1); 15-19