Rectovaginal fistulas are among the most difficult and emotionally impactful conditions in colorectal surgery. In this episode, we explore the causes, diagnosis, and management of rectovaginal fistulas with a focus on both the surgical and human aspects of care.
We begin by breaking down the anatomy and mechanisms that lead to fistula formation, including obstetric injury, surgical complications, inflammatory bowel disease, and radiation. Listeners will gain an understanding of how these pathways differ and why the underlying cause strongly influences treatment decisions.
The conversation then shifts to diagnosis, highlighting the importance of history, physical examination, and imaging. We discuss when endoscopy or MRI is useful and how multidisciplinary collaboration—often involving colorectal surgeons, urogynecologists, and radiologists—creates the most accurate map of the fistula tract.
Treatment strategies are covered in depth. Topics include:
Conservative measures and the rare instances when observation may be appropriate.
Local repairs, advancement flaps, and sphincteroplasty for select cases.
Tissue interposition techniques, including Martius flap and gracilis muscle transposition.
Complex and recurrent fistulas, where diversion or staged approaches may be necessary.
Emerging methods, including biologics and minimally invasive techniques.
Throughout the episode, we emphasize the patient perspective. Rectovaginal fistulas carry a heavy burden—social, emotional, and physical. By framing surgical decision-making in terms of not just anatomy but quality of life, we aim to bring a compassionate lens to this complex problem.
By the end of the episode, listeners will understand the full landscape of rectovaginal fistulas: how they form, how they are best evaluated, and the principles guiding surgical repair. This discussion provides a structured framework for trainees, a reference for practitioners, and a source of clarity for patients navigating a difficult diagnosis.
Rectourethral and complex fistulas represent some of the most challenging conditions in colorectal and urologic surgery. In this episode, we take a structured deep dive into the anatomy, causes, diagnostic pathways, and management strategies for these rare but highly impactful problems.
The discussion begins with the basics—how rectourethral fistulas form, whether from surgical complications, radiation, trauma, or inflammatory disease. We then move into clinical presentation, highlighting the key symptoms that can guide early recognition and prevent delayed diagnosis.
Diagnostic strategies are explored in detail, from physical examination to advanced imaging and endoscopic evaluation. Listeners will learn why multidisciplinary input from both colorectal and urologic perspectives is essential to building an accurate treatment plan.
We then walk through management options, balancing the complexity of surgical repair with the need to preserve continence, urinary function, and overall quality of life. From diversion strategies to complex reconstructive approaches, this episode provides clarity on when and why different techniques are chosen.
Finally, we highlight the patient journey—covering the impact of these fistulas on daily life, the role of staged treatment, and the importance of setting realistic expectations for recovery.
By the end of the episode, listeners will have a comprehensive framework for understanding rectourethral and complex fistulas: how they occur, how they are diagnosed, and how modern surgical strategies aim to restore both anatomy and function. This episode is a must-listen for medical trainees, healthcare professionals, and anyone seeking clear insight into one of the most demanding areas of colorectal and pelvic surgery.
Anorectal abscesses and fistulas are among the most complex and misunderstood conditions in colorectal disease. In this in-depth episode, we take a clear, step-by-step journey into the anatomy, pathophysiology, diagnosis, and treatment strategies surrounding cryptoglandular disease. Whether you are a medical trainee, a healthcare professional, or a patient seeking to understand your own condition, this episode is designed to provide both clarity and depth on a topic that too often remains shrouded in confusion.
We begin with the fundamentals: what an anorectal abscess is, how it forms, and why the anal glands play such a central role in cryptoglandular infections. From there, the discussion expands into the natural progression of untreated abscesses, the development of fistula tracts, and the complex decision-making required when selecting the right treatment strategy.
Listeners will gain insight into the clinical presentation of abscesses and fistulas, including hallmark symptoms, subtle diagnostic signs, and the role of physical examination versus imaging modalities. We break down when MRI or endoanal ultrasound can be helpful, and why accurate mapping of fistula tracts is crucial before any intervention.
Treatment strategies are explored in detail. On the abscess side, incision and drainage remains the gold standard, but timing, technique, and postoperative care can dramatically influence outcomes. On the fistula side, we review both traditional and cutting-edge techniques:
Setons for staged drainage and long-term control.
Fistulotomy and its role in low, simple tracts.
LIFT procedures, advancement flaps, and plug techniques for sphincter-preserving management.
Emerging technologies, including laser ablation, biologic approaches, and novel devices that aim to improve healing while reducing recurrence.
The episode also highlights the tension every surgeon faces: the balance between definitive cure and preservation of continence. High transsphincteric or complex tracts demand careful judgment, and listeners will hear how decision-making frameworks evolve depending on anatomy, prior surgery, and patient-specific risk factors.
Beyond the technical details, we examine the patient journey. Many individuals face repeated procedures, delayed healing, or recurrent infections that impact their quality of life. By framing abscesses and fistulas not only as surgical problems but also as chronic conditions requiring long-term partnership, we bring compassion and realism into the discussion.
Additional attention is given to:
The epidemiology of cryptoglandular disease.
How Crohn’s disease changes the diagnostic and therapeutic landscape.
Postoperative management strategies that support wound healing and reduce recurrence.
Practical pearls for patients: hygiene, diet, and realistic expectations after surgery.
By the end of this episode, listeners will walk away with a structured, big-picture understanding of anorectal abscesses and fistulas. For medical trainees, it provides a framework to approach one of the most tested topics in colorectal surgery. For patients and families, it offers reassurance, education, and a roadmap of what to expect when facing these difficult but treatable conditions.
This episode is part of a larger educational series devoted to mastering colorectal conditions with clarity and accuracy. Each installment aims to translate years of clinical expertise into knowledge that empowers both learners and patients. Anorectal abscesses and fistulas may be complex, but with the right understanding, they no longer need to feel overwhelming.
In this episode, we take a comprehensive look at two challenging colorectal conditions: anal fissures and anal stenosis. Listeners will learn how to differentiate between them, understand the underlying anatomy and causes, and explore both conservative and surgical treatment strategies. With a clear, physician-led breakdown, this discussion blends clinical expertise with practical insights for patients, trainees, and professionals seeking deeper knowledge in colorectal care.
This "Colorectal Surgery Review" episode provides a deep dive into the rapidly evolving field of advanced endoscopy, framing it as a new surgical frontier called "endoluminal surgery." The discussion is aimed at colorectal surgeons and trainees, highlighting critical techniques, evolving evidence, and key nuances for board exams and clinical practice.
Key topics covered in the episode include:
Historical Context and Evolution: The episode begins by drawing a parallel between the initial skepticism surrounding the adoption of colonoscopy in the 1970s and the current challenges and learning curves associated with advanced techniques like Endoscopic Submucosal Dissection (ESD).
Polypectomy Techniques: The discussion covers the progression of polypectomy methods:
Forceps: It notes that while useful for small polyps, hot biopsy forceps are now recommended against by major guidelines due to tissue damage and a higher risk of delayed bleeding compared to cold techniques.
Cold vs. Hot Snare: There has been a significant shift towards using cold snare polypectomy for many smaller polyps (<10mm), as it has a lower risk of complications like delayed bleeding and perforation while achieving equivalent complete resection rates.
EMR (Endoscopic Mucosal Resection): This "lift and cut" technique is used for larger, flat lesions. It involves a submucosal injection to create a safety cushion before removing the polyp, often in a piecemeal fashion. While effective, this can lead to higher recurrence rates.
ESD (Endoscopic Submucosal Dissection): This is the most advanced technique, allowing for the removal of very large lesions in a single piece ("on-block"). This provides the best possible specimen for pathologists to assess for cancer, offering a potentially curative, organ-sparing option for select patients and avoiding major surgery. However, it is technically demanding with a significant learning curve and higher risks.
Adjunctive Tools and Complication Management:
Endoscopic Clips: The podcast emphasizes a major practice change: routine prophylactic clipping after polypectomy is no longer recommended. However, selective clipping for high-risk lesions (e.g., >20mm, especially in the proximal colon) has been shown to reduce delayed bleeding.
New Technologies: The episode highlights tools that are transforming what is possible, including endoscopic suturing devices for closing large defects or perforations and stabilization platforms (like the double balloon system) that create a more stable environment for complex work inside the colon.
Advanced Applications: The discussion also covers the use of self-expanding metal stents for palliating or as a "bridge to surgery" in malignant large bowel obstructions, as well as their off-label use for managing contained anastomotic leaks.
The central theme is that the role of the colorectal surgeon is expanding, requiring advanced endoscopic skills to manage complex polyps and conditions that previously would have required open or laparoscopic surgery.
This episode of "Colorectal Surgery Review" provides a comprehensive guide to hemorrhoidal disease for clinicians, with a focus on details relevant for board exams and clinical practice. The hosts emphasize that hemorrhoids are normal anatomical structures (vascular cushions) and only require treatment when they become symptomatic.
Key topics covered in the episode include:
Anatomy and Classification: The podcast stresses the critical distinction between internal and external hemorrhoids based on their position relative to the dentate line.
Internal hemorrhoids are proximal to the line, have visceral innervation (making them insensitive to pain), and are graded on a scale from I to IV based on their degree of prolapse.
External hemorrhoids are distal to the line, have somatic innervation (making them painful), and are not graded.
Diagnosis: Diagnosis is primarily clinical, based on a thorough history and physical exam, which must include a digital rectal exam and anoscopy. A key takeaway is that any patient over 45 with rectal bleeding or other alarm symptoms requires a colonoscopy to rule out malignancy, as this is a common reason for missed cancer diagnoses.
Treatment: The approach to treatment is stepwise and depends on the type and grade of the hemorrhoids.
Medical Management: This is the foundation of treatment for nearly all patients. It includes increasing dietary fiber and fluid intake, avoiding straining, practicing good hygiene (like sitz baths), and using short-term topical medications.
Office-Based Procedures: These are effective for symptomatic grade I-III internal hemorrhoids. The main options discussed are rubber band ligation (RBL), energy ablation (like infrared photocoagulation), and sclerotherapy.
Surgical Management (Hemorrhoidectomy): This is reserved for patients who fail other treatments or have advanced (grade III-IV) or complicated (e.g., strangulated) disease. The podcast details several techniques:
Excisional Hemorrhoidectomy: Considered the "gold standard" for its low recurrence rate, with discussion of both the closed (Ferguson) and open (Milligan-Morgan) techniques.
Stapled Hemorrhoidopexy: Noted to have less initial pain but a significantly higher rate of recurrence and the risk of rare but severe complications.
Doppler-Guided Hemorrhoidal Artery Ligation (HAL): A less invasive surgical option, but may also have a higher recurrence rate than excisional surgery.
Postoperative Care: A multimodal, narcotic-sparing approach to pain management is emphasized, using techniques like pudendal nerve blocks with long-acting anesthetics (liposomal bupivacaine), NSAIDs, and stool softeners to ensure a smoother recovery.
Special Populations: The episode concludes by discussing tailored management strategies for patients who are pregnant, have Crohn's disease, are immunocompromised, or have portal hypertension.
Key topics covered in the episode include:
Definition and Physiology: Fecal incontinence is defined as the uncontrolled passage of stool or gas for at least one month in a person who had previously achieved continence. Continence relies on a complex interplay of five factors: stool consistency, anal sphincter function, rectal compliance (the rectum's ability to store stool), neurologic function, and pelvic floor coordination.
Evaluation: A thorough evaluation begins with a detailed patient history and the use of scoring systems like the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) to quantify severity. This is followed by a meticulous physical exam. Diagnostic tests discussed include anorectal manometry, anal ultrasound, defecography, and colonoscopy to rule out other pathologies. The speakers note that neurophysiology tests like PNTML and EMG have largely fallen out of favor due to a lack of predictive power.
Treatment Options: Treatment is highly individualized and progresses from conservative to more invasive options.
Conservative: Initial management includes dietary modifications, medications like loperamide, fiber supplements, and bowel management systems such as enemas or the Peristeen anal irrigation device.
Minimally Invasive: Options include biofeedback, anal plugs, and the Eclipse vaginal bowel control system.
Advanced Interventions: Sacral neuromodulation (SNM) is highlighted as a cornerstone treatment, with the important update that it is now considered effective for patients both with and without sphincter defects. The podcast also covers injectable bulking agents and notes that procedures like percutaneous tibial nerve stimulation (PTNS) and radiofrequency energy (Secca procedure) have shown limited effectiveness in robust trials.
Surgical and Historical: The discussion covers surgical repairs like sphincteroplasty (for traumatic defects) and ventral mesh rectopexy (for prolapse). It also reviews several procedures that are now considered historical or are not available in the U.S., including the artificial bowel sphincter and dynamic graciloplasty.
Definitive Management: For severe, refractory cases, a definitive diversion such as a colostomy or ileostomy is presented as a final option that can profoundly improve a patient's quality of life.
The overarching message is that a tailored, stepwise approach is essential for managing fecal incontinence, with a focus on matching the specific etiology and patient expectations to the most appropriate therapy.
In this episode, we review the principles and practice of endoscopy in colorectal surgery. Topics include indications for diagnostic and therapeutic endoscopy, scope design and function, and the essential steps for safe technique. We cover screening colonoscopy, polypectomy, management of bleeding, and evaluation of inflammatory bowel disease, as well as the role of endoscopy in cancer detection and surveillance. Clinical pearls and common pitfalls are highlighted to guide fellows and practicing surgeons in applying endoscopy effectively and safely in daily practice.
This episode reviews the physiology of the anorectum, focusing on the mechanisms of continence and defecation. We cover the anatomy and function of the internal and external anal sphincters, the puborectalis muscle, and the rectoanal inhibitory reflex. Sensory pathways, autonomic and somatic innervation, and the role of the pelvic floor are explained in detail, along with the coordination required for continence and evacuation. Clinical correlations include constipation, fecal incontinence, and functional anorectal disorders, with attention to how physiology guides surgical decision-making.
In this episode, we explore the physiology of the colon — a vital but often misunderstood organ. Beginning with embryology, we review how the colon and rectum develop from the primitive gut, including the rotations of the midgut and the complex differentiation of the cloaca. These processes explain congenital anomalies such as malrotation, Hirschsprung’s disease, and anorectal malformations.
We then move to anatomy and function. The colonic wall contains four distinct layers — mucosa, submucosa, muscularis propria, and serosa — with specialized epithelial cells including enterocytes, goblet cells, and neuroendocrine cells. Stem cells at the crypt base continually regenerate the mucosa, balancing absorption and secretion.
The epithelium plays a critical role in electrolyte and water balance. Sodium absorption and potassium secretion are tightly regulated, influenced by hormones such as aldosterone, while chloride and bicarbonate exchange underlies many diarrheal disorders. Pathophysiologic states such as infectious diarrhea, Clostridium difficile colitis, and inflammatory bowel disease disrupt these transport systems, with clinical consequences ranging from dehydration to metabolic acidosis.
Short-chain fatty acids, particularly butyrate, are highlighted as key energy sources for colonocytes. These microbial metabolites not only support epithelial health but also influence immune regulation and wound healing, with implications in colitis and colorectal cancer prevention. The colon also absorbs vitamin K, produced both by diet and by resident microbiota, reinforcing the intimate relationship between host physiology and bacterial metabolism.
We next examine innervation and motility. The colon is regulated by both extrinsic autonomic pathways and intrinsic enteric plexuses. Interstitial cells of Cajal act as pacemakers for motility. Propulsive activity ranges from segmental contractions to high-amplitude propagated contractions, the latter driving mass movements associated with defecation. Neuromodulators such as acetylcholine, nitric oxide, serotonin, and opioids influence tone and peristalsis, explaining therapeutic targets for constipation and irritable bowel syndrome.
Colonic motility integrates with continence mechanisms. The rectoanal inhibitory reflex, sphincteric control, and pelvic floor function determine whether defecation is postponed or allowed, emphasizing the complex neuromuscular choreography that underpins bowel function.
Finally, we turn to the microbiome. Housing more than 100 trillion bacteria, the colon is both shaped by and dependent on its microbial community. These organisms generate metabolites, modulate immunity, and influence disease states including IBS, IBD, and colorectal cancer. We also discuss the impact of antibiotics, probiotics, and prebiotics on microbial balance and clinical outcomes.
By the end of this review, listeners will understand the colon not only as an absorptive and motile organ, but as a dynamic system whose physiology is inseparable from its development, innervation, and microbial ecology. This foundation is essential for approaching both common and complex pathologies encountered in colorectal surgery.
We begin with the anal canal and pelvic floor. In colorectal surgery, it’s important to distinguish between the anatomic anal canal and the surgical anal canal. Continence depends on a coordinated set of muscles: the internal and external anal sphincters, and the puborectalis. The canal is lined by different epithelial types, with the dentate line as the critical landmark. That line separates endoderm from ectoderm, and it also marks a division in nerve supply, blood supply, and lymphatic drainage.
Moving proximally, we examine the rectum. Its divisions, its blood supply from the superior, middle, and inferior rectal arteries, and the surrounding fascial planes are central to cancer surgery. Structures like the mesorectum and Denonvilliers’ fascia guide oncologic dissection. We also need to know the anorectal spaces — the ischioanal and supralevator spaces, among others — because they can harbor or spread infection.
The colon itself extends from the cecum to the sigmoid. Its hallmark features are the taeniae coli, the haustra, and the appendices epiploicae. The colon is supplied by both the superior and inferior mesenteric arteries, with the watershed zone at the splenic flexure carrying clinical significance. Venous drainage, lymphatic drainage, and autonomic innervation form a complex network with surgical and oncologic implications.
Finally, embryology. The rectum and anus derive from the hindgut, while the colon comes from both midgut and hindgut. Midgut rotation during fetal life occurs in three stages; errors in this process lead to anomalies such as malrotation, non-rotation, or omphalocele. Other congenital disorders to recognize include Hirschsprung’s disease, colonic atresia, and the spectrum of anorectal malformations.
