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Background Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. Methods This is an institutional review board approved, retrospective case series report. Results TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m2. Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). Conclusion TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.

PURPOSE: We report two cases of spontaneous anal passage of a large bowel ‘cast’ caused by acute ischemic injury. METHODS: Clinical, laboratory, endoscopic, and pathologic features were reviewed, and the literature was searched for similar cases. RESULTS: An 85-year-old male who had undergone aortic surgery recovered from rectosigmoid ischemia after undergoing a descending colostomy. A 74-year-old male with severe pancreatitis developed a postischemic sigmoid stricture but did not have operative treatment before death of pneumonia three months after the episode. A literature review revealed six cases of passage of a large bowel cast. In the eight total patients, infarcted muscularis propria was found in seven specimens, five patients had a diversion procedure, and seven survived. CONCLUSION: Passage of a large bowel cast is an extraordinary complication of ischemia that often requires diverting surgery, and most patients survive the ischemic injury.

The topic of perianal infections covers a broad range of illnesses that can be difficult to differentiate from each other. As a result, patients may suffer from unnecessary examinations and ineffective or delayed therapeutic interventions. This article reviews common and unusual infectious pathology and inflammatory or malignant conditions that should be considered in the differential diagnosis. Presentations of infectious pathology specific to HIV are discussed. New treatment strategies, where available, are noted.

PURPOSE: This study was undertaken to report an adverse outcome of the routine use of Fleet® Phospho®-Soda for bowel cleansing and to review the available literature. METHOD: Report of a case and review of the literature is presented. RESULT: Administration of Fleet® Phospho®Soda for bowel preparation in an adult resulted in hyperphosphatemia and hypocalcemic tetany. Review of the literature shows this to be the first such report. Further evaluation suggests a role for partial bowel obstruction and renal failure in this complication. CONCLUSION: Although Fleet® Phospho®-Soda solution continues to be a safe bowel preparation, caution should be used in adults with bowel obstruction and renal failure.

INTRODUCTION: Multiple case reports have suggested that laparoscopic resection of colon cancer may alter the pattern or incidence of cancer recurrence. All reports lack a significant denominator to evaluate the incidence of surgical wound recurrence. We hypothesized that wound recurrence incidence is not increased by laparoscopic resection of colon cancer. METHODS: A prospective registry was initiated under the auspices of The American Society of Ccolon and Rectal Surgeons, American College of Surgeons, and Society of American Gastrointestinal Endoscopic Surgeons in 1992. Patients having laparoscopic colon resection were voluntarily entered and followed until June 1995. Recurrences were evaluated by the primary surgeon and reported to the registry. RESULTS: A total of 504 patients treated for cancer were identified in the registry. A minimum follow-up of one year was obtained for 480 of 493 evaluable patients (97.4 percent). Wound recurrence was identified in five patients (1.1 percent). Recurrence status was unknown in 18 patients (3.8 percent). CONCLUSION: Wound recurrence rates appear to be low. Although length of follow-up is limited, patterns of recurrence from previous studies suggest that 80 percent of recurrences should have occurred within one year. Given the limitations of a Phase II study, the hypothesis that recurrence rate is low is supported. However, prospective randomized trials are needed to establish if any difference in wound recurrence rates after laparoscopic or open resection of colorectal cancer exists.

PURPOSE: Traditional therapy for patients with terminal ileitis found at laparotomy for appendicitis has been to perform appendectomy when the cecum is normal and to leave the diseased ileum in place. METHODS: To determine the role of ileocolic resection in the setting of acute ileitis, records of 1,421 patients with Crohn's disease seen from 1986 to 1994 were retrospectively reviewed. RESULTS: Crohn's disease was found at laparotomy for presumed appendicitis in 36 patients (2.5 percent). Ten patients underwent ileocolic resection, 23 had appendectomy, and 3 had exploratory laparotomy alone. One patient whose appendix was removed also had ileocecal bypass. Of the 36 patients, 20 were women and 16 were men. Mean age at operation was 24 (range, 11–61) years, and mean follow-up time was 14 (range, 0.1–49) years. After initial ileocolic resection, five patients (50 percent) required no further resection, with a mean follow-up time of 12.4 (range, 4–19) years. None required more than three ileocolic resections, with a mean follow-up time of 18.1 (range, 4–49) years. Of 26 patients treated traditionally, 24 (92 percent) required ileocolic resection for intractability or complications of Crohn's disease. Thirty-eight percent required resection within one year and 65 percent within three years (intractability, 8; obstruction, 3; fistula, 4; and perforation, 2). Of 24 patients who subsequently underwent resection, only 6 (25 percent) required further small-bowel resection for Crohn's disease, with a mean follow-up time of 13 (range, 0.1–34) years. CONCLUSION: The majority of patients found to have Crohn's disease at laparotomy for appendicitis required early ileocolic resection. Therefore, the traditional dictum of nonoperative therapy for these patients may not be in their best long-term interest and merits re-evaluation.

Introduction: Anal ultrasound, using a rigid, non-endoscopic trans-rectal ultrasound probe, is reported to accurately diagnose anal sphincter defects due to post-obstetrical trauma in the evaluation of fecal incontinence. However most gastroenterologists in the United States who perform EUS use a radial scanning echoendoscope system designed with fiberoptic or video optics to assist in upper GI endosonography, and not a dedicated rigid rectal ultrasound probe system. The purpose of this study was to evaluate the utility of a flexible UGI echoendoscope for diagnosing anal sphincter defects. Methods: Female patients referred for anal sphincter EUS to evaluate fecal incontinence from 11/95-10/99 were included in this retrospective analysis. Anal EUS was performed with either the Olympus GF-UM20 or UM130 radial scanning flexible echoendoscopes. The probe tip was inserted blindly into the anal canal and imaging was performed at 7.5 and 12 MHz without filling the balloon with water. The anterior aspects of the internal (IAS) and external (EAS) anal sphincters were examined for hypoechoic defects, which were reported as percent of circumference. IAS thickness was measured from the posterior aspect. Results: 49 women underwent EUS examinations. The median age was 53 (range 27-61). 38 (78%) had some form of defect detected, with 16 (33%) having both IAS and EAS defects, 20 (41%) isolated EAS defect, 2 (4%) isolated IAS defect, and 11 (22%) no defects. Patients with anterior IAS defects had a median defect of 37% (15-50%). Patients with anterior EAS defects had a median defect of 35% (10-60%). The IAS thickness was a median of 3 mm (1-4 mm). Among the 12 patients who also underwent anal manometry, 9/12 patients had both normal IAS and normal resting anal sphincter pressures. All 12 patients had low anal sphincter squeeze pressures, and 7/12 also had EAS defects. During median follow-up of 12.5 months (2-48), 10/36 (28%) patients with EAS defects underwent surgical sphincteroplasty. Conclusions: 1. EUS using a flexible upper GI echoendoscope can diagnose post-obstetrical anal sphincter defects. 2. Anal EUS information complements anorectal manometry. 3. Most patients with EUS anal sphincter defects do not undergo surgical sphincteroplasty. 4. Anal sphincter EUS performed with a flexible UGI radial scanning echoendoscope can be used in the evaluation of fecal incontinence if rigid anal ultrasound probe equipment is not available. This work was supported in part by a grant from the ASGE/ADHF.