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Verkade C, Brouwers L, Stijns J, van Dal V, Wasowicz DK, de Kiefte M, van Tilborg F, Zimmerman DDE. Validation of a 3D-printed model of cryptoglandular perianal fistulas. Tech Coloproctol 2024; 28:59. [PMID: 38801550 DOI: 10.1007/s10151-024-02925-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/31/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Visualising the course of a complex perianal fistula on imaging can be difficult. It has been postulated that three-dimensional (3D) models of perianal fistulas improve understanding of the perianal pathology, contribute to surgical decision-making and might even improve future outcomes of surgical treatment. The aim of the current study is to investigate the accuracy of 3D-printed models of perianal fistulas compared with magnetic resonance imaging (MRI). METHODS MRI scans of 15 patients with transsphincteric and intersphincteric fistulas were selected and then assessed by an experienced abdominal and colorectal radiologist. A standardised method of creating a 3D-printed anatomical model of cryptoglandular perianal fistula was developed by a technical medical physicist and a surgeon in training with special interest in 3D printing. Manual segmentation of the fistula and external sphincter was performed by a trained technical medical physicist. The anatomical models were 3D printed in a 1:1 ratio and assessed by two colorectal surgeons. The 3D-printed models were then scanned with a 3D scanner. Volume of the 3D-printed model was compared with manual segmentation. Inter-rater reliability statistics were calculated for consistency between the radiologist who assessed the MRI scans and the surgeons who assessed the 3D-printed models. The assessment of the MRI was considered the 'gold standard'. Agreement between the two surgeons who assessed the 3D printed models was also determined. RESULTS Consistency between the radiologist and the surgeons was almost perfect for classification (κ = 0.87, κ = 0.87), substantial for complexity (κ = 0.73, κ = 0.74) and location of the internal orifice (κ = 0.73, κ = 0.73) and moderate for the percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.63, ICC 0.52). Agreement between the two surgeons was substantial for classification (κ = 0.73), complexity (κ = 0.74), location of the internal orifice (κ = 0.75) and percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.77). CONCLUSIONS Our 3D-printed anatomical models of perianal fistulas are an accurate reflection of the MRI. Further research is needed to determine the added value of 3D-printed anatomical models in preoperative planning and education.
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Affiliation(s)
- C Verkade
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - L Brouwers
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - J Stijns
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, University Hospital Brussels, Brussels, Belgium
| | - V van Dal
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - D K Wasowicz
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - M de Kiefte
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- 3D Laboratory, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - F van Tilborg
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- 3D Laboratory, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - D D E Zimmerman
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
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Katsube S, Matsumoto S, Misawa M, Kakizawa N, Hashimoto R, Mizutani T, Matsumoto K, Yoshikawa S, Mashima H. Successful Fistula Closure After Treatment with Colostomy and Infliximab in a Patient with Ulcerative Colitis Complicated by Rectovaginal Fistula. Biologics 2024; 18:107-113. [PMID: 38736705 PMCID: PMC11086393 DOI: 10.2147/btt.s457300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/23/2024] [Indexed: 05/14/2024]
Abstract
The patient was a 50-year-old Japanese woman who was diagnosed with total-colitis-type ulcerative colitis (UC) at the age of 26 years. She was treated with mesalazine and azathioprine, and her disease activity was well controlled. At the age of 50 years, the patient was experiencing fever, abdominal pain, diarrhea, bloody stool, and anal pain, which led to a diagnosis of a relapse of UC. Although steroid therapy was administered and tended to improve her symptoms, fecaloid vaginal discharge occurred, and rectovaginal fistula (RVF) was confirmed. Colostomy was performed, and infliximab was initiated as maintenance therapy for UC. All symptoms improved, and RVF closure was confirmed 6 months after the initiation of infliximab. To date, she has been free from relapse of UC. There have been only a few reports of UC complicated by RVF, and this condition is often difficult to treat. To the best of our knowledge, no other case of UC complicated by RVF in which the fistula was closed after treatment with colostomy and infliximab has been previously reported; thus, our report of the present case is valuable to the literature.
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Affiliation(s)
- Sota Katsube
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masahiro Misawa
- Department of Obstetrics and Gynecology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nao Kakizawa
- Department of General and Gastrointestinal Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Ryo Hashimoto
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Taku Mizutani
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Keita Matsumoto
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shuhei Yoshikawa
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Williams PJ, St John S, Kazazian K, Okrainec AE, Chadi SA. Low anterior resection with natural orifice specimen extraction performed with the HUGO robotic assisted surgery system-a video vignette. Colorectal Dis 2024. [PMID: 38706088 DOI: 10.1111/codi.16995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 03/30/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Phillip J Williams
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shabier St John
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karineh Kazazian
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Allan E Okrainec
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sami A Chadi
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Garg P, Ladukar L, Yagnik VD, Bhattacharya K, Kaur G. Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas. Clin Exp Gastroenterol 2024; 17:97-108. [PMID: 38646156 PMCID: PMC11032160 DOI: 10.2147/ceg.s456855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024] Open
Abstract
Background Many rectovaginal fistulas(RVF), especially low RVF, do not involve/penetrate the RV-septum, but due to lack of proper nomenclature, such fistulas are also managed like RVF (undertaking repair of RV-septum) and inadvertently lead to the formation of a high RVF (involving RV-septum) in many cases. Therefore, REctovaginal Fistulas, Not Involving the Rectovaginal Septum, should be Treated like Anal fistulas(RENISTA) to prevent any risk of injury to the RV septum. This concept(RENISTA) was tested in this study. Methods RVFs not involving RV-septum were managed like anal fistulas, and the RV-septum was not cut/incised. MRI, objective incontinence scoring, and anal manometry were done preoperatively and postoperatively. High RVF (involving RV-septum) were excluded. Results Twenty-seven patients with low RVF (not involving RV-septum) were operated like anal fistula[age:35.2±9.2 years, median follow-up-15 months (3-36 months)]. 19/27 were low fistula[<1/3 external anal sphincter(EAS) involved] and fistulotomy was performed, whereas 8/27 were high fistula (>1/3 EAS involved) and underwent a sphincter-sparing procedure. Three patients were excluded. The fistula healed well in 22/24 (91.7%) patients and did not heal in 2/24 (8.3%). The healing was confirmed on MRI, and there was no significant change in mean incontinence scores and anal pressures on tonometry. RV-septum injury did not occur in any patient. Conclusions RVF not involving RV-septum were managed like anal fistulas with a high cure rate and no significant change in continence. RV-septum injury or formation of RVF with septum involvement did not occur in any patient. The RENISTA concept was validated in the present study. A new classification was developed to prevent any inadvertent injury to the RV-septum.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Panchkula, Haryana, India
| | - Laxmikant Ladukar
- Department of Surgery, Ladukar Surgical Hospital, Bramhapuri, Maharashtra, India
| | - Vipul D Yagnik
- Department of Surgery, Banas Medical College and Research Institute, Palanpur, Gujarat, India
| | - Kaushik Bhattacharya
- Department of Surgery, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
| | - Gurleen Kaur
- Department of Pharmacology, Adesh Medical College and Hospital, Shahbad, Haryana, India
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Crook DL, Padfield O. A systematic review and meta-analysis of the use of packing in the management of perianal abscesses. Ann R Coll Surg Engl 2024. [PMID: 38563064 DOI: 10.1308/rcsann.2023.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Perianal abscesses are common presentations and reasons for emergency general surgery admissions. Management involves incision and drainage of the abscess and packing the cavity with internal wound dressings. This meta-analysis aimed to assess in adults if packing an abscess or leaving it unpacked leads to a significant difference in the outcomes of pain on wound dressing, time to healing, rate of fistulation and abscess recurrence. METHODS Randomised controlled trials (RCTs) with participants aged 18 years or older that compared packing of perianal abscess cavities with no packing between 2002 and 2022 were searched for in December 2022 on OVID Medline and Embase, the CENTRAL register of trials, PubMed and Google Scholar. Risk of bias was assessed using the Cochrane Risk of Bias tool. Random effects meta-analysis was conducted on the data extracted. RESULTS Three RCTs involving 490 patients were analysed for the outcomes of abscess recurrence and postoperative fistula formation; the data were not adequate to assess pain on dressing and time to healing. For unpacked versus packed, the pooled relative risk of abscess recurrence was 1.57 (95% confidence interval (CI) 0.764, 3.29, p=0.219) and for fistula formation 0.686 (95% CI 0.430, 1.09, p=0.114). These results suggest there is no significant benefit to packing abscess cavities. CONCLUSIONS Analysis of the outcomes suggests there is no significant difference with regards to rates of abscess recurrence or fistula formation between the packed and unpacked groups; however, appropriately powered RCTs are required in this area to provide more primary evidence to inform best practice and clinical management.
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Barzola E, Kajmolli A, Gachabayov M, Bergamaschi R. Repair of radiation-induced rectovaginal fistula with rectal stricture by a combined Tuttle, Turnbull-Cutait and Singapore flap approach. Updates Surg 2024; 76:713-717. [PMID: 38006473 DOI: 10.1007/s13304-023-01701-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/27/2023]
Abstract
Radiation-induced rectovaginal fistula (RI-RVF) with associated rectal stricture represents a challenging problem in management. The aim of the present technical note is to describe a surgical technique aimed at minimizing disease recurrence by avoiding radiated tissue in the reconstruction: 1. Tuttle longitudinal incision of posterior vaginal wall with sharp excision of proximally located fistula; 2. Resection of strictured rectum via a combined transvaginal/laparotomy access, reconstruction with Turnbull-Cutait colon pull-through, and delayed handsewn coloanal anastomosis with loop ileostomy; 3. Bridge closure of the posterior vaginal wall by the interposition of a Singapore flap. This approach resulted in a favorable outcome at the 1-year follow-up in one patient with a medical history of gynecological carcinoma status after hystero-salpingo-oophorectomy followed by adjuvant radiation.
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Affiliation(s)
- E Barzola
- Section of Colorectal Surgery, Department of Surgery, New York Medical College, Westchester Medical Center, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA.
| | - A Kajmolli
- Section of Colorectal Surgery, Department of Surgery, New York Medical College, Westchester Medical Center, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
| | - M Gachabayov
- Section of Colorectal Surgery, Department of Surgery, New York Medical College, Westchester Medical Center, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
| | - R Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, New York Medical College, Westchester Medical Center, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
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Swindon D, Izwan S, Ng J, Chan E, Abbas N, Von Papen M, Sahebally SM. Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis. ANZ J Surg 2024. [PMID: 38475976 DOI: 10.1111/ans.18922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Rectovaginal fistulae (RVF) are notoriously challenging to treat. Martius flap (MF) is a technique employed to manage RVF, among various others, with none being universally successful. We aimed to assess the outcomes of RVF managed with MF interposition. METHODS A PRISMA-compliant meta-analysis searching for all studies specifically reporting on the outcomes of MF for RVF was performed. The primary objective was the mean success rate, whilst secondary objectives included complications and recurrence. The MedCalc software (version 20.118) was used to conduct proportional meta-analyses of data. Weighted mean values with 95% CI are presented and stratified according to aetiology where possible. RESULTS Twelve non-randomized (11 retrospective, 1 prospective) studies, assessing 137 MF were included. The mean age of the study population was 42.4 (±15.7), years. There were 44 primary and 93 recurrent RVF. The weighted mean success rate for MF when performed for primary RVF was 91.4% (95% CI: 79.45-98.46; I2 = 32.1%; P = 0.183) and that for recurrent RVF was 77.5% (95% CI: 62.24-89.67; I2 = 58.1%; P = 0.008). The weighted mean complication rate was 29% (95% CI: 8.98-54.68; I2 = 85.4%; P < 0.0001) and the overall recurrence rate was 12.0% (95% CI: 5.03-21.93; I2 = 52.3%; P = 0.021). When purely radiotherapy-induced RVF were evaluated, the mean overall success rate was 94.6% (95% CI: 83.33-99.75; I2 = 0%; P = 0.350). CONCLUSIONS MF interposition appears to be more effective for primary than recurrent RVF. However, the poor quality of the data limits definitive conclusions being drawn and demands further assessment with randomized studies.
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Affiliation(s)
- Daisy Swindon
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Sara Izwan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Justin Ng
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Erick Chan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Naveed Abbas
- Department of Colorectal Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Michael Von Papen
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Shaheel Mohammad Sahebally
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Department of Colorectal Surgery, Tallaght University Hospital, Dublin, Ireland
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Xu J, Mei Z, Wang Q. Integrating multidisciplinary perspectives in complex anal fistula management: a blueprint for future research and precision surgery. Int J Surg 2024; 110:1810-1812. [PMID: 38052018 PMCID: PMC10942177 DOI: 10.1097/js9.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Jin Xu
- Department of Anorectal Surgery, Baoshan District Hospital of Integrated Traditional Chinese and Western Medicine
| | - Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Qingming Wang
- Department of Anorectal Surgery, Baoshan District Hospital of Integrated Traditional Chinese and Western Medicine
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine
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Yang J, Li Q, Li H, Zhang H, Ren D, Zhang Z, Su D, Qian H. Preoperative assessment of fistula-in-ano using SonoVue enhancement during three-dimensional transperineal ultrasound. Gastroenterol Rep (Oxf) 2024; 12:goae002. [PMID: 38419722 PMCID: PMC10899812 DOI: 10.1093/gastro/goae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/07/2023] [Accepted: 12/22/2023] [Indexed: 03/02/2024] Open
Abstract
Background Accurate preoperative evaluation of fistula-in-ano can guide the choice of surgical procedure and may improve healing rates. This prospective study aimed to evaluate the accuracy of conventional 3D transperineal ultrasound (3D-TPUS) compared with SonoVue (SVE)-enhanced 3D-TPUS for the detection and classification of anal fistula. Methods In this prospective study, 3D-TPUS reconstructions were performed before and after SVE enhancement in 60 patients with fistula-in-ano who intended to undergo surgery at the Department of Anorectal Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University (P. R. China) between January 2021 and October 2021. Accuracies of anal fistula classification, complexity classification, detection of anal fistula branches, and detection of internal opening between 3D-TPUS and SVE 3D-TPUS were compared based on a reference standard-intraoperative findings. Results This study enrolled 60 patients (mean age, 37.1 ± 11.4 years; mean follow-up, 9 ± 3 months). Intraoperative findings showed that the fistula type was intersphincteric in 23 patients (38.3%), trans-sphincteric in 35 (58.3%; 12 high and 23 low), and suprasphincteric in 2 (3.3%). Moreover, 68 internal openings were found. Compared with the accuracy of 3D-TPUS, that of SVE 3D-TPUS was similar in fistula classification [95.0% (57/60) vs 96.7% (58/60), P = 0.392], but significantly higher in internal opening evaluation [80.9% (55/68) vs 97.1% (66/68), P = 0.001], complexity classification [85.0% (51/60) vs 98.3% (59/60), P = 0.018], and detection of fistula branches [70.4% (19/27) vs 92.6% (25/27), P = 0.031]. Conclusions SVE 3D-TPUS may be a useful examination for patients with perianal fistulae because of its high accuracy and consistency with intraoperative findings, especially in complex fistula-in-ano and difficult cases.
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Affiliation(s)
- Jun Yang
- Department of Anorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P. R. China
- Department of Anorectal Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, P. R. China
| | - Qing Li
- Department of Anorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P. R. China
- Department of Anorectal Surgery, Xingtai People's Hospital, Hebei Medical University, Xingtai, Hebei, P. R. China
| | - Hua Li
- Department of Surgical Oncology, Xingtai People's Hospital, Hebei Medical University, Xingtai, Hebei, P. R. China
| | - Heng Zhang
- Department of Colorectal and Anal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Donglin Ren
- Department of Colorectal and Anal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Zhiyi Zhang
- Department of Ultrasound in Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, P. R. China
| | - Dan Su
- Department of Colorectal and Anal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Haihua Qian
- Department of Anorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, P. R. China
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Ding C, Chen Y, Yan J, Wang K, Tan SS. Risk factors for therapy failure after incision and drainage alone for perianal abscesses in children. Front Pediatr 2024; 12:1342892. [PMID: 38390277 PMCID: PMC10881786 DOI: 10.3389/fped.2024.1342892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/16/2024] [Indexed: 02/24/2024] Open
Abstract
Background It is well known that recurrent perianal abscesses (PAs) and fistula-in-ano (FIA) are the main causes of therapy failure following incision and drainage (I&D) for PAs. But few studies have focused on the risk factors for therapy failure after I&D for PAs in children. In this study, we retrospectively examine the risk factors for therapy failure after I&D for PAs in children in a pediatric tertiary care institution. Methods A retrospective review of all outpatient children with PA treated by I&D at Beijing Children's Hospital between January 2021 and December 2022 was performed. A follow-up was conducted in October 2023. Patients with other predisposing factors for perianal infection, such as inflammatory bowel disease, hematologic tumor, and anorectal surgery, were excluded from this study. Logistic regression yielding odds ratios (ORs) was used to assess the significance of variables for therapy failure. Results Of 160 children initially identified, follow-up was available for 146, with a total of 172 treatments. A total of 91% of children were male. The median (interquartile range) age at I&D was 2 (1, 15) months. The median follow-up duration was 20 (14, 25) months. Therapy failure occurred in 25 (15%) treatments performed for the prevention of recurrence of PA and in 35 (20%) treatments for the prevention of development of FIA. In the univariate analysis, a history of PA (P = 0.001), history of I&D (P = 0.014), and multilocal occurrence (P = 0.003) were associated with therapy failure. A sitz bath after I&D (P = 0.016) and regular cleaning of the wound after I&D (P = 0.024) were associated with therapy success. In the multivariate analysis, a history of PA (P = 0.015, OR = 3.374) and multilocal occurrence (P = 0.012, OR = 4.649) were independently associated with therapy failure. Regular cleaning of the wound (P = 0.017, OR = 0.341) and sitz bath (P = 0.001, OR = 0.128) after I&D were independently associated with therapy success. Conclusions A history of PA and multilocal occurrence were predictor factors for therapy failure before I&D. Regular cleaning of the wound and sitz bath after I&D were protective factors for therapy success. Therefore, regular cleaning of the wound and sitz bath after I&D should be emphasized in all children with PAs, especially in those with a history of PA and multilocal occurrence.
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Affiliation(s)
- CaiLin Ding
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - YaJun Chen
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - JiaYu Yan
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Kai Wang
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Sarah Siyin Tan
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
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11
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Garg P, Mongia A. Transanal opening of the intersphincteric space (TROPIS): a novel procedure on the horizon to effectively manage high complex anal fistulas. Ann Coloproctol 2024; 40:74-81. [PMID: 38414123 PMCID: PMC10915533 DOI: 10.3393/ac.2022.01263.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 02/29/2024] Open
Abstract
Anal fistulas, especially complex and high fistulas, are difficult to manage. The transanal opening of the intersphincteric space (TROPIS) procedure was first described in 2017, and a high success rate of over 90% was reported in high complex fistulas. Since then, more studies and even a meta-analysis have corroborated the high efficacy of this procedure in high fistulas. Conventionally, the main focus was to close the internal (primary) opening for the fistula to heal. However, most complex fistulas have a component of the fistula tract in the intersphincteric plane. This component is like an abscess (sepsis) in a closed space (2 muscle layers). It is a well-known fact that in the presence of sepsis, healing by secondary intention leads to better results than attempting to heal by primary intention. Therefore, TROPIS is the first procedure in which, instead of closing the internal opening, the opening is widened by laying open the fistula tract in the intersphincteric plane so that healing can occur by secondary intention. Although the drainage of high intersphincteric abscesses through the transanal route was described 5 decades ago, the routine utilization of TROPIS for the definitive management of high complex fistulas was first described in 2017. The external anal sphincter (EAS) is completely spared in TROPIS, as the fistula tract on either side of the EAS is managed separately-inner (medial) to the EAS by laying open the intersphincteric space and outer (lateral) to the EAS by curettage or excision.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India
- Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, India
| | - Anvesha Mongia
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India
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De Gregorio M, Sidhu A, Behrenbruch C, Connor SJ, Guerra G, Johnston MJ, Keck JO, Ong EJSK, Thompson AJ, Woods R, D'Souza B, Ding NS. Preferred definitive surgical management of Crohn's perianal fistulas and factors influencing surgical decision making in Australia and New Zealand. ANZ J Surg 2024; 94:14-16. [PMID: 37551939 DOI: 10.1111/ans.18640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023]
Affiliation(s)
- Michael De Gregorio
- Gastroenterology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ankur Sidhu
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Cori Behrenbruch
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Susan J Connor
- South West Sydney Clinical Campuses, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Department of Medicine, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Gastroenterology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Glen Guerra
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michael J Johnston
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - James O Keck
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Eugene J S K Ong
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alexander J Thompson
- Gastroenterology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Rodney Woods
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Basil D'Souza
- Colorectal Surgery Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Colorectal Surgery Department, Northern Health, Melbourne, Victoria, Australia
| | - Nik S Ding
- Gastroenterology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Yarahmadi A, Afkhami H. The role of microbiomes in gastrointestinal cancers: new insights. Front Oncol 2024; 13:1344328. [PMID: 38361500 PMCID: PMC10867565 DOI: 10.3389/fonc.2023.1344328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/20/2023] [Indexed: 02/17/2024] Open
Abstract
Gastrointestinal (GI) cancers constitute more than 33% of new cancer cases worldwide and pose a considerable burden on public health. There exists a growing body of evidence that has systematically recorded an upward trajectory in GI malignancies within the last 5 to 10 years, thus presenting a formidable menace to the health of the human population. The perturbations in GI microbiota may have a noteworthy influence on the advancement of GI cancers; however, the precise mechanisms behind this association are still not comprehensively understood. Some bacteria have been observed to support cancer development, while others seem to provide a safeguard against it. Recent studies have indicated that alterations in the composition and abundance of microbiomes could be associated with the progression of various GI cancers, such as colorectal, gastric, hepatic, and esophageal cancers. Within this comprehensive analysis, we examine the significance of microbiomes, particularly those located in the intestines, in GI cancers. Furthermore, we explore the impact of microbiomes on various treatment modalities for GI cancer, including chemotherapy, immunotherapy, and radiotherapy. Additionally, we delve into the intricate mechanisms through which intestinal microbes influence the efficacy of GI cancer treatments.
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Affiliation(s)
- Aref Yarahmadi
- Department of Biology, Khorramabad Branch, Islamic Azad University, Khorramabad, Iran
| | - Hamed Afkhami
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
- Cellular and Molecular Research Center, Qom University of Medical Sciences, Qom, Iran
- Department of Medical Microbiology, Faculty of Medicine, Shahed University, Tehran, Iran
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14
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Schrum CJ, Dickinson MM, Shah ED, Speicher MR, Strohbehn K. Utilization of Rectal Examinations Before Magnetic Resonance Defecography Studies. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:153-160. [PMID: 37737745 DOI: 10.1097/spv.0000000000001404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
IMPORTANCE More information is needed to guide referring subspecialists on the appropriate patient evaluation before magnetic resonance defecography (MRD). OBJECTIVES This study aimed to evaluate how often health care providers perform digital rectal examination (DRE) before ordering MRD to investigate causes of bowel and pelvic floor complaints. STUDY DESIGN We conducted a retrospective cohort review, including MRD performed on female patients at an integrated health care system from 2016 through 2020. The primary outcome was the presence or absence of documented rectal examination in the year before defecography by the referring provider or 6 months prior by a primary care physician or pelvic floor physical therapist. We hypothesized that the overall rate of rectal examination would be high and unaffected by the referring provider's subspecialty. RESULTS Three hundred-four defecography tests were performed, with 209 patients (68.8%) referred by gastroenterology providers and 95 (31.2%) from other specialties. Gastroenterologists performed DRE in 32.8% of patients, in contrast to 84.4% of patients referred by other specialties ( P < 0.001). When comparing subspecialties that most commonly refer patients for MRD (gastroenterology, colorectal surgery and urogynecology), there was a statistically significant difference between gastroenterologists and colorectal surgeons ( P < 0.001) as well as urogynecologists ( P < 0.001) but no difference in the rate of rectal examination between colorectal surgeons and urogynecologists ( P = 1.00). CONCLUSIONS At our single integrated health system, the rate of DRE before MRD testing varied significantly by specialty. Our findings highlight the need for better understanding of DRE utility in the algorithms for evaluation of bowel and pelvic floor disorders.
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Affiliation(s)
- Colby J Schrum
- From the Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Eric D Shah
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Mark R Speicher
- American Association of Colleges of Osteopathic Medicine, Bethesda, MD
| | - Kris Strohbehn
- From the Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Yuan Y, Li S, Li F, Zhou Y, Qiang S, Che K, Wang K, Yang K, Li Q. Modified Internal Pudendal Artery Perforator Flap Interposition for Rectovaginal Fistula. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00164. [PMID: 38373234 DOI: 10.1097/spv.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
IMPORTANCE Rectovaginal fistula (RVF) is a challenging condition associated with recurrences and significant functional impairment. OBJECTIVES The internal pudendal artery perforator (IPAP) flap has become a viable option for reconstructing the vagina and perineal regions. This study aims to introduce a modified technique of IPAP flap interposition and evaluate its postoperative outcomes in the treatment of low RVF. STUDY DESIGN Sixteen patients with RVF who underwent modified IPAP flap interposition between 2016 and 2021 were retrospectively enrolled. Recurrence rate, the satisfaction of vulvar appearance (Visual Analog Scale), and quality of sexual life (Female Sexual Function Index score) were followed up and analyzed. RESULTS All patients presented with low fistula with a mean diameter of 8.3 mm. The mean width and length of the IPAP flaps were 3.8 and 6.2 cm, respectively. The mean follow-up period was 14.1 months. All patients achieved successful healing without recurrence. High satisfaction was reported for the cosmetic effect of the vulva with a mean Visual Analog Scale score of 8.4. The proportion of female sexual disorder exhibited a statistically significant reduction, decreasing from 100% preoperatively to 38% after surgery (P < 0.05). CONCLUSIONS The modified IPAP flap interposition is a reliable and safe option for repairing low RVF, with high success rates and minimal donor site morbidity. Moreover, this procedure provides a suitable volume flap and preserves the vaginal physiological environment, which benefits postoperative sexual function.
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Affiliation(s)
- Ye Yuan
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Senkai Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengyong Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhou
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuai Qiang
- Plastic Surgery Department, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kexin Che
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keke Wang
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Yang
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Shan J, Wang J, Lu D, Yu X, Zheng L, Zhang Y. Simplified dressing change after surgery for high anal fistula: A prospective, single centre randomized controlled study on loose combined cutting seton (LCCS) technique. Int Wound J 2024; 21:e14401. [PMID: 37709499 PMCID: PMC10788579 DOI: 10.1111/iwj.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Dressing change is the most important part of postoperative wound care. The aim of this study was to evaluate whether a more effective, simple and less painful method of dressing change for anal fistulas could be found without the need for debridement and packing. Data related to postoperative recovery were recorded at postoperative days 3, 7, 14, 21 and 180. METHODS In this experiment, 76 subjects diagnosed with high anal fistula were randomly divided into a simplified dressing change (SDC) group and a traditional debridement dressing change(TDDC) group according to a ratio of 1:1. RESULTS The SDC group had significantly fewer pain scores, bleeding rates, dressing change times, inpatient days and lower average inpatient costs than the TDDC group. There were no significant differences in wound healing time, area and depth and Wexner score between the two groups. CONCLUSIONS Studies have shown that the use of simplified dressing changes does not affect cure or recurrence rates, but significantly reduces dressing change times and pain during changes, reducing patient inpatient length of stay and costs.
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Affiliation(s)
- Jiaying Shan
- Department of Andrology, Dongzhimen HospitalBeijing University of Chinese MedicineBeijingChina
| | - Jin Wang
- Department of Andrology, Dongzhimen HospitalBeijing University of Chinese MedicineBeijingChina
| | - Dongdong Lu
- Department of Andrology, Dongzhimen HospitalBeijing University of Chinese MedicineBeijingChina
| | - Xudong Yu
- Department of Andrology, Dongzhimen HospitalBeijing University of Chinese MedicineBeijingChina
| | - Lihua Zheng
- Department of ProctologyChina‐Japan Friendship HospitalBeijingChina
| | - Yaosheng Zhang
- Department of Andrology, Dongzhimen HospitalBeijing University of Chinese MedicineBeijingChina
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17
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Tomasicchio G, Giove C, Dezi A, Picciariello A, Lantone V, Martines G, De Fazio M, Rinaldi M. The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton. Updates Surg 2024; 76:163-167. [PMID: 38123906 DOI: 10.1007/s13304-023-01713-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023]
Abstract
The management of trans-sphincteric anal fistula (TAF) includes several surgical options; however, during the COVID-19 pandemic, the access to the operating rooms was severely limited, leaving only the choice of minimally invasive procedures. This study aimed to evaluate the safety and effectiveness of the slow cutting seton technique for TAF performed in an outpatient setting during the COVID-19 pandemic.Patients treated for TAF between January 2020 and July 2022 and followed-up for at least 12 months were retrospectively evaluated. A vascular silicone tie used as seton was positioned in the fistula tract using a Lockhart-Mummery fistula probe. The seton was maintained in moderate tension until the sphincter muscle was passed. Percentage and time for healing, recurrence, SF-36, VAS and Vaizey's Score were recorded.Fifty-eight patients [36 male/22 female, median age 56.5 years (IQR 41.25-65.75) [with TAF were included. After a median time of 4 months, complete healing occurred in 53 cases (91.5%), the anal pain VAS decreased from 6 to 0, the anal incontinence scores did not change significantly and the QoL improved significantly in all the SF36 domains. No complications were recorded, but the fistula recurred in five cases (8.5%). Two of them had additional seton treatment, and three underwent other surgical procedures after the COVID-19 emergency.The slow cutting seton technique is a safe and effective treatment for outpatient procedure with minimal patient discomfort. This treatment option in healthcare delivery for TAF should be reconsidered, even outside the limited in-hospital access during the COVID-19 pandemic.
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Affiliation(s)
- G Tomasicchio
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - C Giove
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - A Dezi
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy.
| | - A Picciariello
- Department of Experimental Medicine, University of Salento, Lecce, Italy
| | - V Lantone
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - G Martines
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - M De Fazio
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - M Rinaldi
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
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Stacy S, Belcher E, Nazarey PP, Cazzetta SE, Salinas GD. Patient and Caregiver Perspectives on Their Experiences With Crohn's Perianal Fistulas. CROHN'S & COLITIS 360 2024; 6:otad081. [PMID: 38259605 PMCID: PMC10803099 DOI: 10.1093/crocol/otad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Indexed: 01/24/2024] Open
Abstract
Background Little is known about patients' perception of care and management of Crohn's perianal fistulas (CPF). This study was conducted to understand US patient and caregiver attitudes and challenges to CPF care. Methods Patients with CPF and caregivers of patients with CPF completed a 36-question survey about their perceptions and challenges regarding the diagnosis, treatment, and overall management of CPF. Patients/caregivers were recruited via online Crohn's and fistula support group websites and forums and via their gastroenterologists (GEs) and surgeons from October 2020 through January 2021. Results The survey was completed by 96 patients and 54 caregivers. Respondents reported over 60% and 14%-23% of CPF were diagnosed and treated by a GE or surgeon, respectively. Nearly all patients/caregivers wanted to be involved in treatment decision-making with their physicians (81%). While the majority of patients/caregivers were satisfied with their quality of care (65%) and access to care (67%), racial disparities exist and there is room for improvement. A smaller proportion of non-White versus White patients/caregivers reported satisfaction with care quality (39% vs 72%, respectively) and access to care (57% vs 69%, respectively). Half of non-White patient/caregivers (50%) versus 69% of White patient/caregivers knew where to access CPF information. Most patients/caregivers (69%) stated that they would benefit from more information on managing day-to-day CPF symptoms. Significant barriers perceived by patients/caregivers to receiving optimal CPF care included lack of effective treatments (69%) and lack of access to specialist care (68%). Conclusions Improvements in multidisciplinary CPF care are required to optimize treatment.
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Salinas GD, Belcher E, Stacy S, Nazarey PP, Cazzetta SE. Understanding the role of the primary care physician in the management of patients with Crohn's perianal fistulas. Postgrad Med 2024; 136:67-77. [PMID: 38445664 DOI: 10.1080/00325481.2023.2277146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/25/2023] [Indexed: 03/07/2024]
Abstract
OBJECTIVES To understand the role of primary care physicians (PCPs) in the recognition, diagnosis, and management of Crohn's perianal fistulas (CPF) and their referral patterns and treatment expectations. METHODS This survey-based study was conducted between September 2020 and October 2020. US-based PCPs managing at least one patient with Crohn's disease per week were included. Participants were presented with two case vignettes relevant to primary care practice; Case Vignette 1 comprised three parts and focused on initial CPF presentation and progression to partial response; Case Vignette 2 focused on recurrent CPF. Survey questions elicited the physician's clinical approach to each case. Data were presented as descriptive statistics. RESULTS Overall, 151 PCPs (median 23 years in practice) who saw about three patients per month with new/existing CPF responded. For Case Vignette 1, upon identification of a fistulous tract, 89% of respondents would refer the patient, mostly to a colorectal surgeon or gastroenterologist. Most PCPs (69%) would begin the patient on medication; 46% would conduct a diagnostic/imaging study. Treatment expectations after referral varied: 55% of respondents believed surgeons would place a seton or use one prior to surgery; 23% expected medical management only; 23% were unsure. Case Vignette 2 revealed that 98% of PCPs preferred to be involved in patient care after referral; however, only 49% were. Of these, 76% considered reinforcing patient treatment adherence as their primary role. While 80% of PCPs were at least moderately satisfied with communication and care coordination with multidisciplinary teams, 52% considered lack of access to specialists as at least a moderate barrier to multidisciplinary team management. CONCLUSION PCPs want more involvement in multidisciplinary management of patients with CPF. Continuing education providing PCPs with up-to-date information on diagnostic modalities, treatment options, early diagnosis, the role of PCPs within a multidisciplinary team, and effective initial CPF care is required.
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Affiliation(s)
- Gregory D Salinas
- Department of Research and Assessment, CE Outcomes, LLC, Birmingham, AL, USA
| | - Emily Belcher
- Department of Research and Assessment, CE Outcomes, LLC, Birmingham, AL, USA
| | - Sylvie Stacy
- Department of Research and Assessment, CE Outcomes, LLC, Birmingham, AL, USA
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Drumond DG, Condé CDMS, Chebli JMDF, Chebli LA, Esperança SD, Speck NMDG. Combined clinical and radiological remission of rectovaginal fistulas using fractional CO2 vaginal laser: a case series and medium-term follow-up. BMC Res Notes 2023; 16:371. [PMID: 38115124 PMCID: PMC10729484 DOI: 10.1186/s13104-023-06666-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION Despite the advances in surgical and clinical approaches, there is no consensus regarding the best line of treatment from rectovaginal fistula (RVF). Faced with a challenging scenario in the approach of RVF, the fractional CO2 laser receives attention as a possible form of treatment. OBJECTIVES A single-center, prospective, open-label study evaluating the effectiveness and safety of laser therapy for RVF treatment. SUBJECTS AND METHODS The total of 15 patients was recruited at the Juiz de Fora University Hospital between August 2018 and July 2022. Inclusion criteria were presence of clinically suspects RVF of any etiology confirmed by pelvic magnetic resonance image (MRI) and gynecological examination. Five fractional CO2 laser sessions with monthly interval followed by complete evaluation through clinical examination and pelvic MRI were performed for all patients after the completion of treatment. Analysis of sexual function before and after the treatment was performed using Female Sexual Quotient (FSQ). RESULTS The evaluation through physical examination showed no persistent inflammatory signs in the vagina for all patients. Additionally, 10 of out 15 (67.7%) patients achieved clinical remission of RVF symptoms, while 33.3% patients reported significant improvement. Of note, five patients who did not have previous sexual activity returned to regular sexual activity while seven patients who have baseline sexual activity had improvement in their sexual function as assessed by the FSQ. Three out of four ostomized patients had their ostomy reversed and remained without complains. All six patients with RVF secondary to Crohn's disease reported a marked improvement in symptoms and sexual function. In seven (47%) patients radiological remission was confirmed by pelvic MRI. CONCLUSION CO2 fractional laser can be considered a promising and safe therapeutic alternative for the management of RVF.
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Affiliation(s)
- Denise Gasparetti Drumond
- Department of Surgery, Faculty of Medicine, Universidade Federal de Juiz de Fora, Rua Doutor Waldyr Lorentz, 11, Juiz de Fora, MG, CEP: 36.037-752, Brazil.
| | | | - Júlio Maria da Fonseca Chebli
- Department of Medicine, Faculty of Medicine, Inflammatory Bowel Disease Center, Universitary Hospital, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
| | - Liliana Andrade Chebli
- Department of Medicine, Faculty of Medicine, Inflammatory Bowel Disease Center, Universitary Hospital, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
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Verkade C, van Tilborg GFAJB, Stijns J, Wasowicz DK, Zimmerman DDE. Distalization of perianal fistulas after loose silicone seton drainage is a myth. Tech Coloproctol 2023; 28:16. [PMID: 38097914 PMCID: PMC10721694 DOI: 10.1007/s10151-023-02882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/25/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND It is often stated that loose seton drainage results in distal migration of a fistula tract in perianal fistula. The aim of the present study was to assess this distalization of trans- and suprasphincteric perianal fistulas after a silicone seton has been inserted. METHODS Consecutive patients who underwent loose seton placement for the management of a transsphincteric or suprasphincteric fistula between January 2016 and December 2021 with a pre- and postoperative magnetic resonance imaging (MRI) were included in the present retrospective study. The height of the external anal sphincter (EAS) and the level of penetration of perianal fistula through the EAS or puborectal muscle (PRM) were determined on MRI. Primary outcome was migration of the fistula tract through the EAS and PRM. RESULTS Thirty-eight patients with perianal fistulas were included. Median height of the EAS was 28 (IQR 25-34) mm before seton placement and 27 (IQR 24-33) mm afterward. Median level of perforation was 32 (IQR 17-40) mm before seton placement and 28 (IQR 17-40) mm afterward (p = 0.37). One fistula (3%) was downgraded from mid to low transsphincteric and was laid open after 14.9 months of loose seton drainage. CONCLUSIONS No statistically significant distalization of complex fistula tracts after loose silicone seton drainage was found. Some complex fistulas may downgrade to a less complex fistula after long-term seton drainage. However, loose silicone seton drainage should not be offered to patients as a treatment option to downgrade a complex fistula to a simple one or even have the hope to heal it.
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Affiliation(s)
- Carolien Verkade
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - G Fiek A J B van Tilborg
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Jasper Stijns
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, University Hospital Brussels, Brussels, Belgium
| | - Daria K Wasowicz
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - David D E Zimmerman
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
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22
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Rogers P, Emile SH, Garoufalia Z, Strassmann V, Dourado J, Ray-Offor E, Horesh N, Wexner SD. Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review. Tech Coloproctol 2023; 28:7. [PMID: 38079014 DOI: 10.1007/s10151-023-02880-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review. METHODS A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure. RESULTS Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%). CONCLUSION Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.
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Affiliation(s)
- P Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S H Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Z Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - V Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - J Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - E Ray-Offor
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- University of Port Harcourt, Dept of Surgery, Choba, Nigeria
| | - N Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - S D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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23
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Brillantino A, Iacobellis F, Brusciano L, Giordano P, Santoro GA, Sudol-Szopinska I, Grillo M, Maglio MN, Foroni F, Palumbo A, Menna MP, Antropoli C, Docimo L, Renzi A. Impact of Preoperative Three-Dimensional Endoanal Ultrasound on the Surgical Outcome of Primary Fistula in Ano. A Multi-Center Observational Study of 253 Patients. Surg Innov 2023; 30:693-702. [PMID: 37776197 DOI: 10.1177/15533506231204821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
PURPOSE To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery. METHODS The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings. RESULTS A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference (P < .0001; Fisher's exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate. CONCLUSION The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.
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Affiliation(s)
| | | | - Luigi Brusciano
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, Naples, Italy
| | | | | | - Iwona Sudol-Szopinska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Diagnostic Imaging, Warsaw Medical University, Warsaw, Poland
| | | | | | | | | | | | | | - Ludovico Docimo
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, Naples, Italy
| | - Adolfo Renzi
- Surgery Department, Ospedale Buonconsiglio Fatebenefratelli, Naples, Italy
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24
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Blanco Terés L, Bermejo Marcos E, Cerdán Santacruz C, Correa Bonito A, Rodríguez Sanchez A, Chaparro M, Gisbert JP, García Septiem J, Martín-Pérez E. FiLaC® procedure for highly selected anal fistula patients: indications, safety and efficacy from an observational study at a tertiary referral center. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:700-706. [PMID: 37449475 DOI: 10.17235/reed.2023.9644/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique. METHODS a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks' classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated. RESULTS a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn's disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048). CONCLUSIONS FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.
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Affiliation(s)
- Lara Blanco Terés
- General and Digestive Surgery, Hospital Universitario La Princesa, España
| | | | | | - Alba Correa Bonito
- General and Digestive Surgery, Hospital Universitario de La Princesa, España
| | | | - María Chaparro
- General and Digestive Surgery, Hospital Universitario de La Princesa, España
| | - Javier P Gisbert
- General and Digestive Surgery, Hospital Universitario de La Princesa, España
| | | | - Elena Martín-Pérez
- General and Digestive Surgery, Hospital Universitario de La Princesa, España
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25
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Drezdzon MK, Peterson CY. Anorectal Emergencies. Surg Clin North Am 2023; 103:1153-1170. [PMID: 37838461 DOI: 10.1016/j.suc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.
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Affiliation(s)
- Melissa K Drezdzon
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin
| | - Carrie Y Peterson
- Division of Colorectal Surgery, Medical College of Wisconsin, HCM A6303, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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26
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Mao X, Huang S, Li B, Liao S, Zhang R, Cai J, Yu H. Efficacious resolution of a rectal subepithelial cold abscess via endoscopic submucosal excavation. Endoscopy 2023; 55:E1176-E1177. [PMID: 37963596 PMCID: PMC10645541 DOI: 10.1055/a-2194-4387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Affiliation(s)
- Xinyue Mao
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
| | - Silin Huang
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
| | - Bo Li
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
| | - Suhuan Liao
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
| | - Ronggang Zhang
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
| | - Jun Cai
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
| | - Heng Yu
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, GuangDong, China
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27
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Gizem GO, Aybuke AK, Arife O, Pelin K, Deniz E, Aysenur A, Incinur GA, Kamer P, Ayse Demet P, Yelda S, Akgun O, Nuri B, Ilker D. Response to a comment regarding 'Perianal abscess in children: an evaluation of microbiological etiology and the effectiveness of antibiotics'. Pediatr Surg Int 2023; 40:3. [PMID: 37991538 DOI: 10.1007/s00383-023-05601-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Guner Ozenen Gizem
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey.
| | - Akaslan Kara Aybuke
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey
| | - Ozer Arife
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey
| | - Kacar Pelin
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey
| | - Ergun Deniz
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey
| | - Aydin Aysenur
- Department of Pediatrics, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Genisol Ataman Incinur
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Polatdemir Kamer
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Payza Ayse Demet
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Sorguc Yelda
- Department of Medical Microbiology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Oral Akgun
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Bayram Nuri
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey
| | - Devrim Ilker
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Konak, 35210, Turkey
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28
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Wei J, Zhang Y, Chen C, Feng X, Yang Z, Feng J, Jiang Q, Fu J, Xuan J, Gao H, Liao L, Wang F. Efficacy and safety of allogeneic umbilical cord-derived mesenchymal stem cells for the treatment of complex perianal fistula in Crohn's disease: a pilot study. Stem Cell Res Ther 2023; 14:311. [PMID: 37904247 PMCID: PMC10617053 DOI: 10.1186/s13287-023-03531-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 10/10/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVES The aim of the study was to evaluate the efficacy and safety of allogeneic umbilical cord-derived mesenchymal stem cells (TH-SC01) for complex perianal fistula in patients with Crohn's disease (CD). METHODS This was an open-label, single-arm clinical trial conducted at Jinling Hospital. Adult patients with complex treatment-refractory CD perianal fistulas (pfCD) were enrolled and received a single intralesional injection of 120 million TH-SC01 cells. Combined remission was defined as an absence of suppuration through an external orifice, complete re-epithelization, and absence of collections larger than 2 cm measured by magnetic resonance imaging (MRI) at 24 weeks after cell administration. RESULTS A total of 10 patients were enrolled. Six patients (60.0%) achieved combined remission at 24 weeks. The number of draining fistulas decreased in 9 (90.0%) and 7 (70.0%) patients at weeks 12 and 24, respectively. Significant improvement in Perianal Crohn Disease Activity Index, Pelvic MRI-Based Score, Crohn Disease Activity Index, and quality of life score were observed at 24 weeks. No serious adverse events occurred. The probability of remaining recurrence-free was 70% at week 52. CONCLUSION The study demonstrated that local injection of TH-SC01 cells might be an effective and safe treatment for complex treatment-refractory pfCD after conventional and/or biological treatments fail (ClinicalTrials.gov ID, NCT04939337). TRIAL REGISTRATION The study was retrospectively registered on www. CLINICALTRIALS gov (NCT04939337) on June 25, 2021.
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Affiliation(s)
- Juan Wei
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Yufei Zhang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Chunyan Chen
- Department of Gastroenterology and Hepatology, The First School of Clinical Medicine, Southern Medical University, Guangzhou Da Dao Bei 1838, Guangzhou, China
| | - Xiaoyue Feng
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Zhao Yang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Jing Feng
- Department of Gastroenterology and Hepatology, The First School of Clinical Medicine, Southern Medical University, Guangzhou Da Dao Bei 1838, Guangzhou, China
| | - Qiong Jiang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Jinjin Fu
- Department of Gastroenterology and Hepatology, The Affiliated Changzhou No. 2 People's Hospital, Nanjing Medical University, Changzhou, China
| | - Ji Xuan
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Hong Gao
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Lianming Liao
- Center of Laboratory Medicine, Union Hospital of Fujian Medical University, No. 29, Xinquan Road, Fuzhou, 350001, People's Republic of China.
| | - Fangyu Wang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China.
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29
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Satora M, Żak K, Frankowska K, Misiek M, Tarkowski R, Bobiński M. Perioperative Factors Affecting the Healing of Rectovaginal Fistula. J Clin Med 2023; 12:6421. [PMID: 37835064 PMCID: PMC10573987 DOI: 10.3390/jcm12196421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
Rectovaginal fistula is rare, but a severe complication in gynecology, which despite the effort of clinicians is still not treated successfully in many cases. According to statistics, the healing rates of surgery in patients with RVF range from 20 to 100%. The treatment effectiveness depends on the etiology of fistula, the age of the patients, the presence of comorbidities, the type of surgery and many other factors. Considering the low efficiency of treatment and the high risk of recurrence, the question of possible methods to improve the results occurs. In our review, we analyzed both modifiable and non-modifiable factors which may influence the treatment, healing rate and future fate of the patients. Taking into account all analyzed risk factors, including age, comorbidities, smoking status, microbiology, medications, stoma and stool features, we are aware that rectovaginal fistula's treatment must be individualized and holistic. In cases of poorly healing RVF, the drainage of feces, the use of antibiotic prophylaxis or the implementation of estrogen therapy may be useful. Moreover, microbiome research in women with RVF and towards estrogen therapy should be performed in order to create treatment algorithms in women with fistulae. Those interventions, in our opinion, may significantly improve the outcome of the patients.
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Affiliation(s)
- Małgorzata Satora
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Marcin Misiek
- Department of Gynecology, Holy Cross Cancer Center, 25-734 Kielce, Poland;
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland;
| | - Marcin Bobiński
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland;
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30
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Vurture G, Kayton M, Staab V, Appelbaum H. Fibrin Glue Repair of a Traumatic Rectovaginal Fistula in a Pediatric Patient. J Pediatr Adolesc Gynecol 2023; 36:491-493. [PMID: 36889455 DOI: 10.1016/j.jpag.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/17/2023] [Accepted: 02/25/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Rectovaginal fistulas are often associated with obstetric trauma and present with leakage of stool or flatus from the vagina. They are often repaired via fistulaectomy, but sometimes more complex repairs are needed. There are limited data regarding success using fibrin glue to close the tract. CASE A developmentally delayed pediatric patient presented with right hip pain. Imaging studies identified a hairpin penetrating the rectovaginal space. The hairpin was removed during an exam under anesthesia, and the subsequent rectovaginal fistula was closed with fibrin glue. Closure of the tract has persisted for more than 1 year without need for further intervention. SUMMARY AND CONCLUSION Fibrin glue may be a minimally invasive and safe approach for rectovaginal fistulas in the pediatric patient.
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Affiliation(s)
- Gregory Vurture
- Division of Pediatric Gynecology, Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey.
| | - Mark Kayton
- Division of Pediatric Surgery, Department of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Victoriya Staab
- Division of Pediatric Surgery, Department of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Heather Appelbaum
- Division of Pediatric Gynecology, Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
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31
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La Torre M, Goglia M, Micarelli A, Fiori E, D'Andrea V, Grossi U, Tierno SM, Tomassini F, Gallo G. Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream? Colorectal Dis 2023; 25:2017-2023. [PMID: 37658596 DOI: 10.1111/codi.16732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 09/03/2023]
Abstract
AIM Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre. METHOD Consecutive adult patients with a minimum of 2 years' follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively. RESULTS Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence. CONCLUSION VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.
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Affiliation(s)
- Marco La Torre
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Marta Goglia
- Department of General Surgery, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Alessandro Micarelli
- ITER Centre for Balance and Rehabilitation Research (ICBRR), Rome, Italy
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
| | - Enrico Fiori
- Department of Surgery, Ospedale Figlie di San Camillo Vannini, Rome, Italy
| | - Vito D'Andrea
- Department of Surgery, Ospedale Grassi di Ostia, Rome, Italy
| | - Ugo Grossi
- Department of Surgery, Oncology and Gastroenterology - DISCOG, University of Padua, Padua, Italy
- Surgery Unit 2, Regional Hospital Treviso, AULSS2 Marca Trevigiana, Treviso, Italy
| | | | | | - Gaetano Gallo
- Department of Surgery, Sapienza University of Rome, Rome, Italy
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32
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Guner Ozenen G, Akaslan Kara A, Ozer A, Kacar P, Ergun D, Aydin A, Genisol Ataman I, Polatdemir K, Payza AD, Sorguc Y, Oral A, Bayram N, Devrim I. Perianal abscess in children: an evaluation of microbiological etiology and the effectiveness of antibiotics. Pediatr Surg Int 2023; 39:272. [PMID: 37695379 DOI: 10.1007/s00383-023-05556-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE We aimed to evaluate the demographic characteristics of children with perianal abscess, distribution of microbiological etiology, antibiotic susceptibility, and identify the effectiveness and coverage of antibiotics due to culture results. METHODS A retrospective study was designed to evaluate pediatric patients with perianal abscesses between January 2013 and December 2022. RESULTS A total of 197 episodes in 135 patients were evaluated. The median age of the patients was 10 months (22 days-17 years). The isolated microorganisms were Gram-positive bacteria in 56 (28.4%) patients and Gram-negative bacteria in 141 (71.6%) patients. The most common isolated species was Escherichia coli (n = 70, 35.5%), followed by Klebsiella spp. (n = 48, 24.4%), Staphylococcus aureus (n = 37, 18.9%), and Enterobacter spp. (n = 9, 4.5%). Forthy-two percent (n = 58) of isolates were positive for extended-spectrum beta-lactamase, 8% (n = 11) were carbapenem-resistant in Gram-negative bacteria, and 37.5% (n = 21) were methicillin-resistant, 7.1% (n = 4) were vancomycin-resistant in Gram-positive bacteria. According to bacterial culture results, ertapenem plus glycopeptide had the highest antimicrobial coverage rate (92.3%), followed by ertapenem plus clindamycin (89.8%), ertapenem (81.7%), third-generation cephalosporin plus glycopeptide (82.2%), third-generation cephalosporin plus clindamycin (69.5%). CONCLUSION Ertapenem can be a good choice in the empirical treatment of perianal abscesses in children due to its high coverage rate.
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Affiliation(s)
- Gizem Guner Ozenen
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey.
| | - Aybuke Akaslan Kara
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey
| | - Arife Ozer
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey
| | - Pelin Kacar
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey
| | - Deniz Ergun
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey
| | - Aysenur Aydin
- Department of Pediatrics, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Incinur Genisol Ataman
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Kamer Polatdemir
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Ayse Demet Payza
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Yelda Sorguc
- Department of Medical Microbiology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Akgun Oral
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Nuri Bayram
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey
| | - Ilker Devrim
- Department of Pediatric Infectious Diseases, University of Health Sciences Dr. Behçet Uz Children's Hospital, Konak, Izmir, 35210, Turkey
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Varsamis N, Kosmidis C, Chatzimavroudis G, Apostolidou Kiouti F, Efthymiadis C, Lalas V, Mystakidou CM, Sevva C, Papadopoulos K, Anthimidis G, Koulouris C, Karakousis AV, Sapalidis K, Kesisoglou I. Preoperative Assessment of Perianal Fistulas with Combined Magnetic Resonance and Tridimensional Endoanal Ultrasound: A Prospective Study. Diagnostics (Basel) 2023; 13:2851. [PMID: 37685389 PMCID: PMC10486944 DOI: 10.3390/diagnostics13172851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND we designed a prospective study of diagnostic accuracy that compared pelvic MRI and 3D-EAUS with pelvic MRI alone in the preoperative evaluation and postoperative outcomes of patients with perianal fistulas. METHODS the sample size was 72 patients and this was divided into two imaging groups. MRI alone was performed on the first group. Both MRI and 3D-EAUS were performed in parallel on the second group. Surgical exploration took place after two weeks and was the standard reference. Park's classification, the presence of a concomitant abscess or a secondary tract, and the location of the internal opening were recorded. All patients were re-evaluated for complete fistula healing and fecal incontinence six months postoperatively. All of the collected data were subjected to statistical analysis. RESULTS the MRI group included 36 patients with 42 fistulas. The MRI + 3D-EAUS group included 36 patients with 46 fistulas. The adjusted sensitivity and negative predictive value were 1.00 for most fistula types in the group that underwent combined imaging. The adjusted specificity improved for intersphincteric fistulas in the same group. The adjusted balanced accuracy improved for all fistula types except rectovaginal. The combination of imaging methods showed improved diagnostic accuracy only in the detection of a secondary tract. The healing rate at six months was 100%. Fecal incontinence at six months did not present a statistically significant difference between the two groups (Fisher's exact test p-value > 0.9). Patients with complex perianal fistulas had a statistically significant higher probability of undergoing a second surgery (x2 test p-value = 0.019). CONCLUSIONS the combination of pelvic MRI and 3D-EAUS showed improved metrics of diagnostic accuracy and should be used in the preoperative evaluation of all patients with perianal fistulas, especially those with complex types.
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Affiliation(s)
- Nikolaos Varsamis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Christoforos Kosmidis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Grigorios Chatzimavroudis
- Second Surgical Department, “G. Gennimatas” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 41 Eth. Aminis Steet, 54635 Thessaloniki, Greece;
| | - Fani Apostolidou Kiouti
- Biostatistics Unit, Medical Faculty, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | | | - Vasilis Lalas
- Radiology Department, “Euromedica” Diagnostic Center, 35 Gr. Lampraki & Ag. Dimitriou Street, 54638 Thessaloniki, Greece;
| | | | - Christina Sevva
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Konstantinos Papadopoulos
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - George Anthimidis
- Surgical Department, European Interbalkan Medical Center, 10 Asklipiou Street, 55535 Thessaloniki, Greece;
| | - Charilaos Koulouris
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Alexandros Vasileios Karakousis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Konstantinos Sapalidis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Isaak Kesisoglou
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
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Drusany Starič K, Distefano REC, Campo G, Norčič G. Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned. Front Surg 2023; 10:1260355. [PMID: 37693638 PMCID: PMC10483572 DOI: 10.3389/fsurg.2023.1260355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
Background Rectovaginal fistulas following an obstetric anal sphincter injury's repair are rare in developed country and their management could be challenging, particularly in cases of delayed repair. This study emphasizes the importance of accurately diagnosing and promptly repairing such fistulas for optimal patient well-being. Case A 30-year-old patient presented with gas incontinence and a greenish discharge from the vagina, 6 months after delivering her baby. Examination revealed a small pinhole lesion on the posterior vaginal wall, and an endoanal ultrasound confirmed the presence of a rectovaginal fistula. Surgical repair was delayed for 9 months due to the patient's breastfeeding. The fistula was eventually repaired through a transrectal approach, with excision of the fistulous tract and closure of both the rectum and vagina. A laparoscopic protective ileostomy was also performed due to the delayed repair. However, a recurrence of the fistula was detected 8 months later, requiring a second repair. The patient underwent physiotherapy for the anal sphincter and achieved optimal sphincter function. After 6 months, the ileostomy was successfully closed, and the patient remained continent. Conclusions This case highlights the importance of early recognition and prompt repair of rectovaginal fistulas following obstetric anal sphincter injury. Delayed repairs pose greater challenges and increase the risk of recurrence. Individualized surgical approaches, skilled pelvic floor repair, and a multidisciplinary approach are crucial for successful outcomes. This case underscores the need for careful planning and consideration of patient characteristics in the management of rectovaginal fistulas, aiming to achieve optimal outcomes and patient well-being.
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Affiliation(s)
- Kristina Drusany Starič
- Division of Gynaecology and Obstetrics, Department of Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Rosario Emanuele Carlo Distefano
- Division of General Surgery and Medical Surgical Specialties, Department of Obstetrical and Gynecological Pathology, University of Catania, Catania, Italy
| | - Giorgia Campo
- Division of General Surgery and Medical Surgical Specialties, Department of Obstetrical and Gynecological Pathology, University of Catania, Catania, Italy
| | - Gregor Norčič
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Vo DT, Nguyen TTT, Nguyen NH, Nguyen LTT, Nguyen TTT, Phan CC. Preoperative magnetic resonance imaging of anal fistulas with scrotal extension: a retrospective study. Front Surg 2023; 10:1224931. [PMID: 37545842 PMCID: PMC10397721 DOI: 10.3389/fsurg.2023.1224931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction This study aimed to elucidate the magnetic resonance (MR) characteristics of anal fistulas extending to the scrotum, and the applicable rules, and to correlate MR features with surgical findings. Methods We conducted a retrospective study in 150 consecutive patients with anal fistulas extending into the scrotum, who were diagnosed and underwent surgery at University Medical Center Ho Chi Minh City between January 2017 and April 2022. MR findings were evaluated and compared with surgical findings using Cohens kappa coefficient (k) with a 95% confidence interval. Results 150 patients (mean age 37.6 ± 10.9 years) with 166 fistulas, including 150 anal fistulas with scrotal extension. Most fistulas were low transsphincteric (80.0%, 120/150 patients). There was a strong agreement for primary tract classification and detecting the location of internal openings between MRI and surgical findings with k = 0.83 (0.780.87) and k = 0.89 (0.85 0.93) (p<0.001), respectively. There is a significant correlation between the location of internal openings and the type of fistula (p<0.05). Low transsphincteric fistulas were predominant in the anterior group (103/122 patients vs. 10/19 patients), while in the posterior group, it was more common in the high transsphincteric fistulas (7/19 patients vs. 14/122 patients), and the intersphincteric fistulas (1/19 patients vs. 5/122 patients); and the suprasphincteric fistulas were only seen in the posterior group (1 patient). Conclusion Anal fistulas with scrotal extension are exceptions to Goodsalls rule. Albeit long-tract fistulas, most are low transsphincteric and have anterior internal openings.
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Affiliation(s)
- Duc Tan Vo
- Department of Diagnostic Imaging, University Medical Center, Ho Chi Minh City, Vietnam
- Department of Radiology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Truc Thi Thuy Nguyen
- Department of Radiology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nam Hoang Nguyen
- Department of Radiology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Linh Thi Thuy Nguyen
- Department of Radiology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | | | - Chien Cong Phan
- Department of Diagnostic Imaging, University Medical Center, Ho Chi Minh City, Vietnam
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Weng MT, Lin KL, Huang YL, Karki C, Hong JL, Bennett D, Arnold Chan K, Wei SC. Epidemiology, Disease Course, and Clinical Outcomes of Perianal Fistulas and Fissures Crohn's Disease: A Nationwide Population-Based Study in Taiwan. CROHN'S & COLITIS 360 2023; 5:otad035. [PMID: 37497019 PMCID: PMC10368329 DOI: 10.1093/crocol/otad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Indexed: 07/28/2023] Open
Abstract
Background Population-based data on the course of perianal disease in East Asian populations with Crohn's disease (CD) are limited. This study examined the prevalence, clinical course, and compared the outcomes of CD patients with perianal CD (pCD) versus without pCD in Taiwan. Methods A nationwide population-based study was implemented from 2000 to 2017 by using the Taiwan National Health Insurance Research Database. Results Of 2424 patients with CD, 358 (14.8%) patients with pCD were identified. Most patients with CD and pCD were men (79.3%). The mean age at CD diagnosis was lower in patients with pCD (33.7 years) than in those without pCD (44.9 years). Approximately half the patients with pCD received the pCD diagnosis at least 6 months before receiving a CD diagnosis. Approximately one-third (121/358) of patients with pCD had recurrent fistula; the median recurrence interval was 239 days. Compared with patients without pCD, patients with pCD had higher mean incidences of hospitalization (7.0 vs 3.8, P < .01), outpatient visits (13 vs 2.9, P < .01), and emergency room visits (10.3 vs 4.4, P < .01) over a 15-year period. Although patients with pCD had higher rates of healthcare utilization, their 15-year mortality rate was lower than that of those without pCD (6.1% vs 17.3%, P < .01). Conclusions The period prevalence of pCD in Taiwanese patients with CD was 14.8%. Although patients with pCD required more intensive care and had greater healthcare utilization, they did not have inferior survival outcomes compared with those without pCD.
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Affiliation(s)
- Meng-Tzu Weng
- Department of Medical Research, National Taiwan University Hospital Hsin-Chu Branch, HsinChu, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Kuan-Lin Lin
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Ya-Ling Huang
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Chitra Karki
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Jin-Liern Hong
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Dimitri Bennett
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc., Cambridge, MA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - K Arnold Chan
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Shu-Chen Wei
- Address correspondence to: Shu-Chen Wei, MD, PhD, Division of Hepatology and Gastroenterology, Department of Internal Medicine, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan; or, No. 7 Chung-Shan South Road, Taipei, Taiwan ()
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Bosch-Ramírez M, Sánchez-Guillén L, Alcaide-Quirós MJ, Aguilar-Martínez MM, Bellón-López M, López Delgado A, López-Rodríguez-Arias F, Muñoz-Duyos A, Barber-Valles X, Arroyo A. Long-term efficacy of percutaneous tibial nerve stimulation for faecal incontinence and a new approach for partial responders. Tech Coloproctol 2023; 27:443-451. [PMID: 36222850 PMCID: PMC10169891 DOI: 10.1007/s10151-022-02711-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 09/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) for patients with faecal incontinence (FI) refractory to conservative treatment. Secondary aims were to identify predictors of response and validate new treatment pathways for partial responders. METHODS A prospective, interventional study was carried out in a specialist defecatory disorder unit from a university hospital between January 2010 and June 2017 on patients > 18 years old with FI refractory to conservative treatment. Thirty-minute PTNS sessions were performed in three phases (weekly, biweekly and monthly) up to a year, with clinical reassessment at 3, 6, 12 and 36 months. Patients were classified as optimal responders when their pretreatment Wexner score decreased > 50%; partial responders when it decreased 25-50%; and insufficient responders if it decreased < 25%. Only optimal and partial responders progressed into successive phases. RESULTS Between 2010 and 2017, 139 patients (110 women, median age 63 years [range 22-82 years]) were recruited. After the first phase, 4 patients were optimal responders, 93 were partial responders and 36 were insufficient responders. At 6 and 12 months, 66 and 89 patients respectively were optimal responders, with an optimal response rate of 64% at the end of treatment. A total of 93.3% patients with a partial response initially finally became optimal responders. Furthermore, at 36 months, 71.9% of patients were still optimal responders without supplementary treatment, although their quality of life did not improve significantly. Baseline Wexner scores ≤ 10 and symptom duration < 1 year were identified as predictive factors for positive responses to PTNS. CONCLUSIONS Patients undergoing PTNS for 1 year following this protocol had optimal long-term responses. PTNS sessions for up to 1 year in patients who were partial responders prevents a high percentage of them from needing more invasive treatments, and maintains long-term continence in patients who were optimal responders.
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Affiliation(s)
- M. Bosch-Ramírez
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - L. Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. J. Alcaide-Quirós
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. M. Aguilar-Martínez
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. Bellón-López
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - A. López Delgado
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - F. López-Rodríguez-Arias
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - A. Muñoz-Duyos
- Department of General Surgery, Colorectal Unit, Mútua Terrassa University Hospital, University of Barcelona, Terrassa, Barcelona Spain
| | - X. Barber-Valles
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
- Center for Operations Research, University Miguel Hernández of Elche, Elche, Alicante Spain
- Joint Research Unit on Statistical Methods in Health Sciences UMH-FISABIO, University Miguel Hernández of Elche, Elche, Spain
| | - A. Arroyo
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
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Schwandner O. [Stem Cell Therapy for Complex Anal Fistula in Crohn`s Disease: Current Evidence and Future Perspectives]. Zentralbl Chir 2023; 148:220-227. [PMID: 37267976 DOI: 10.1055/a-2063-3673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Despite progress in multidisciplinary diagnostic and therapeutic strategies, complex anal fistulas associated with Crohn's disease remain a challenge for both medical and surgical management. Conventional surgical techniques such as flap procedures or LIFT are still associated with considerable persistence and recurrence rates. Based on this background, results of stem cell therapy for Crohn's anal fistula have shown promising results and are a sphincter-preserving technique. In particular, adipose-derived, allogeneic stem cell therapy (Darvadstrocel) has shown encouraging healing rates within the randomised controlled ADMIRE-CD trial, which were reproducible in "real world" data of limited clinical studies. The current evidence has led to the integration of allogeneic stem cell therapy into international guidelines. To date, the definitive status of allogeneic stem cells in the multidisciplinary treatment algorithm for complex anal fistulas associated with Crohn's disease cannot be evaluated.
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Affiliation(s)
- Oliver Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland
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Emile SH, Garoufalia Z, Aeschbacher P, Horesh N, Gefen R, Wexner SD. Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials. Surgery 2023:S0039-6060(23)00178-2. [PMID: 37198039 DOI: 10.1016/j.surg.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Rectal advancement flap and ligation of intersphincteric fistula tract are common procedures for treating complex anal fistula. The present meta-analysis aimed to compare the surgical outcomes of advancement flap and ligation of intersphincteric fistula tract. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials comparing the ligation of intersphincteric fistula tract and advancement flap was conducted. PubMed, Scopus, and Web of Science were searched through January 2023. The risk of bias was assessed using the Risk of Bias 2 tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcomes were healing and recurrence of anal fistulas, and secondary outcomes were operative time, complications, fecal incontinence, and early pain. RESULTS Three randomized clinical trials (193 patients, 74.6% male) were included. The median follow-up was 19.2 months. Two trials had a low risk of bias, and 1 had some risk of bias. The odds of healing (odds ratio: 1.363, 95% confidence interval: 0.373-4.972, P = .639), recurrence (odds ratio: 0.525, 95% confidence interval: 0.263-1.047, P = .067), and complications (odds ratio: 0.356, 95% confidence interval: 0.085-1.487, P = .157) were similar between the 2 procedures. Ligation of intersphincteric fistula tract was associated with a significantly shorter operation time (weighted mean difference: -4.876, 95% confidence interval: -7.988 to -1.764, P = .002) and less postoperative pain (weighted mean difference: -1.030, 95% confidence interval: -1.418 to -0.641, 0.198, P < .001, I2 = 3.85%) than advancement flap. Ligation of intersphincteric fistula tract was associated with marginally lower odds of fecal incontinence than advancement flap (odds ratio: 0.27, 95% confidence interval: 0.069-1.06, P = .06). CONCLUSION Ligation of intersphincteric fistula tract and advancement flap had similar odds of healing, recurrence, and complications. The odds of fecal incontinence and extent of pain after ligation of intersphincteric fistula tract were lower than after advancement flap.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Egypt. https://twitter.com/dr_samehhany81
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | - Pauline Aeschbacher
- Department of General Surgery and Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, FL
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Cirocco WC. Exposing Goodsall's Flaw: Remember the Midline Rules! Dis Colon Rectum 2023; 66:e174. [PMID: 36649155 DOI: 10.1097/dcr.0000000000002698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Balan N, Liu JK, Braschi C, Lee H, Petrie BA. Sex-based analysis of characteristics contributing to anorectal abscesses requiring acute care surgery. SURGERY IN PRACTICE AND SCIENCE 2023. [DOI: 10.1016/j.sipas.2023.100156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Charalampopoulos A, Papakonstantinou D, Bagias G, Nastos K, Perdikaris M, Papagrigoriadis S. Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes. Cureus 2023; 15:e35888. [PMID: 36911578 PMCID: PMC9993441 DOI: 10.7759/cureus.35888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/11/2023] Open
Abstract
Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.
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Affiliation(s)
- Anestis Charalampopoulos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Dimitrios Papakonstantinou
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - George Bagias
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Konstantinos Nastos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Markos Perdikaris
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
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Sayers AE, Lee MJ, Brown SR. Improved fistula plug outcome depends on the type of plug: a single-centre retrospective study. Colorectal Dis 2023; 25:995-1001. [PMID: 36727730 DOI: 10.1111/codi.16501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/28/2022] [Accepted: 01/14/2023] [Indexed: 02/03/2023]
Abstract
AIM Fistula-in-ano is a common condition that is potentially difficult to treat. In recent years 'sphincter-sparing' procedures have increased in popularity due to the lower rates of reported complications, such as incontinence. One such treatment is the fistula plug, which has seen varied success compared with other techniques. There are currently several plugs on the market and it is possible that difference in outcomes could be linked to the type of plug used. The aim of this study was to compare healing and complication rates between two fistula plugs in a single tertiary referral centre in the UK. METHOD We conducted a single-centre retrospective analysis of all patients over the age of 18 years who underwent elective fistula plug insertion, with two different fistula plugs over a 13-year period. RESULTS A total of 113 patients underwent fistula plug insertion (plug A n = 90; plug B n = 23). Plug B had been on the market for the final 4 years of the study period, hence the differing patient numbers. There was no difference in patient demographics, fistula type or aetiology of the fistula between the two plugs. Plug B had a significantly higher fistula healing rate compared with plug A (56.5% vs. 12.2%; p < 0.005). A quarter of all patients experienced a complication, 93% being those who had fistula plug A inserted. The most common complication was extrusion of the plug within 72 h of insertion. CONCLUSION This study demonstrated significantly different outcomes according to the type of fistula plug used. Whilst current randomized controlled trials have not found a significant difference in healing rates when comparing one type of fistula plug to other treatment modalities, this study suggests that plug type may influence efficacy.
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Affiliation(s)
- Adele E Sayers
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Matthew J Lee
- School of Health and Related Research, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steve R Brown
- School of Health and Related Research, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Narayanan S, Althans AR, Reitz KM, Allen LH, Kurukulasuriya C, Larkin TM, Reinert NJ, Cunningham KE, Watson AR, Celebrezze JP, Medich DS, Holder-Murray J. Drainage of anorectal abscesses in the operating room is associated with a decreased risk of abscess recurrence and fistula formation. Am J Surg 2023; 225:347-351. [PMID: 36150906 PMCID: PMC9999175 DOI: 10.1016/j.amjsurg.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/23/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation. METHODS Index episodes of anorectal abscesses treated with I&D in 2014-2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation. RESULTS A total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114-0.367]). CONCLUSIONS Improved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.
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Affiliation(s)
- Sowmya Narayanan
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alison R Althans
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura H Allen
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Timothy M Larkin
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Nathan J Reinert
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kellie E Cunningham
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew R Watson
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James P Celebrezze
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David S Medich
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Yin H, Luo B, Wang Q, Hong Z, Chen H, Shen L, Shen B, Hu B. Differences in Gut Microbiota between Healthy Individuals and Patients with Perianal Abscess before and after Surgery. Mediators Inflamm 2023; 2023:1165916. [PMID: 37091905 PMCID: PMC10115528 DOI: 10.1155/2023/1165916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 03/13/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
Surgery is the most important treatment for perianal abscesses. However, the gut microbiota of patients with perianal abscess and the effects of perianal abscess on the gut microbiota after surgery are unknown. In this study, significant changes in interleukin 6 and tumor necrosis factor-α in the blood of healthy subjects, patients with perianal abscesses, and patients after perianal abscess surgery were identified. 16S rRNA gene sequencing technology was used to detect the changes in the gut microbiota among 30 healthy individuals and 30 patients with perianal abscess before and after surgery. Venn diagrams and alpha diversity analyses indicated differences in the abundance and uniformity of gut microbiota between the healthy individuals and patients with perianal abscesses before and after surgery. Beta diversity analysis indicated that the grouping effects among the control, abscess, and surgery groups were good. The classification and compositional analysis showed significant differences in the gut microbiota between healthy individuals and patients with perianal abscesses before and after surgery. LEfSe analysis, random forest analysis, and ROC curve analysis showed that Klebsiella (AUC = 0.7467) and Bilophila (AUC = 0.72) could be potential biomarkers for the diagnosis of perianal abscess. The functional prediction results showed that the differential microbiota is significantly enriched in the pathways related to nutrition and drug metabolism. This study may have important implications for the clinical management and prognostic assessment of patients with perianal abscesses.
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Affiliation(s)
- Hezhai Yin
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Bairu Luo
- Department of Clinical Pathology, Jiaxing University Master Degree Cultivation Base, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Qi Wang
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Zhonghua Hong
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Huilin Chen
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Lidong Shen
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Bin Shen
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
| | - Bo Hu
- Department of Surgery, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Jiaxing, 314001 Zhejiang, China
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