Pneumorrhachis Secondary to a Locally Advanced Rectal Cancer with Pre-Sacral Abscess-Case Report and Review

The occurrence of pneumorrhachis (PR), defined as the presence of air within the spinal canal, presents a complex clinical picture with diverse etiological factors. We report an exceedingly rare case of PR arising from locally advanced rectal cancer accompanied by a pre-sacral abscess. This report aims to enhance awareness and understanding of rare causes of PR within the medical community, particularly among surgeons engaged in emergency procedures. The patient survived the acute phase of the disease through multiple surgical interventions and admission to the intensive care unit, but succumbed to cardiovascular complications three weeks later. We also offer a brief review of the literature concerning PR originating from the colorectal lumen.

Clinical research progress in Traditional Chinese Medicine in treating wound healing after anal fistula surgery

In the study of the mechanism of wound healing after anal fistula surgery, how to scientifically and efficiently promote wound healing is of great significance. At present, modern medical treatment of wounds after anal fistula surgery mostly focuses on physical therapy intervention, new wound dressing and packing, and external application of growth factors. However, these therapies have many problems, and there is still no consensus on their clinical use. Traditional Chinese Medicine (TCM) has several methods to promote wound healing, such as oral administration, rubbing, and fumigation, which have a long history and obvious efficacy, but research in this area is relatively scattered and lacks classification and summarizing. Therefore, this paper analyzes and summarizes the existing research on TCM for promotion of wound healing after anal fistula surgery, carries out targeted analyses according to different clinical syndromes and treatment methods, and analyzes the defects in current research and anticipates future research trends in order to provide theoretical support for the advantages of TCM in promoting wound healing after anal fistula surgery.

Nutritional status in perianal Crohn's disease: are we underestimating the impact?

Symptomatic perianal disease is common in patients with Crohn's disease (CD), and perianal fistulas represent the primary form of anal involvement. This type of involvement is associated with a poor prognosis and a disabling course. The treatment is challenging and involves both surgical and medical approaches. Despite combined therapy, a significant portion of patients may still require proctectomy to control the symptoms. Consequently, investigating factors that may influence the outcome of perianal disease remains a priority area of research in CD. Nutritional deficiencies are well documented among CD patients with luminal forms of involvement and are closely related to poor clinical outcomes, therapy response, and postoperative complications. As a result, leading guidelines recommend regular nutritional assessment and correction of nutritional deficiencies in patients requiring a surgical approach. Despite these recommendations and the high rate of surgeries among CD patients with perianal disease, there is a shortage of studies addressing the real impact of nutritional status on the course and outcomes of perianal disease. This knowledge gap underscores the importance of further research to understand better and improve the management of perianal CD. This narrative review aims to provide an overview of nutritional status assessment and the influence of nutritional status on the outcomes of patients with perianal CD.

Three-dimensional modelling as a novel interactive tool for preoperative planning for complex perianal fistulas in Crohn's disease

AIM

The aim of this study is to demonstrate the added value of three-dimensional (3D) reconstruction models and artificial intelligence for preoperative planning in complex perianal Crohn's disease. MRI is the gold standard for diagnosis of complex perianal fistulas and abscess due to its high sensitivity, but it lacks high specificity values. This creates the need for better diagnostic models such as 3D image processing and reconstruction (3D-IPR) with artificial intelligence (AI) algorithms.

METHOD

This is a prospective study evaluating the utility of 3D reconstruction models from MRI in four patients with perineal Crohn's disease (pCD).

RESULTS

Four pCD patients had 3D reconstruction models made from pelvic MRI. This provided a more visual representation of perianal disease and made possible location of the internal fistula orifice, seton placement in fistula tracts and abscess drainage.

CONCLUSION

Three-dimensional reconstruction in CD-associated complex perianal fistulas can facilitate disease interpretation, anatomy and surgical strategy, potentially improving preoperative planning as well as intraoperative assistance. This could probably result in better surgical outcomes to control perianal sepsis and reduce the number of surgical procedures required in these patients.

Negative Pressure Wound Therapy for the Treatment of Fournier's Gangrene: A Rare Case with Rectal Fistula and Systematic Review of the Literature

Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.

Treatment of Fistulizing Perianal Crohn's Disease by Autologous Microfat Enriched With Adipose-Derived Regenerative Cells

In this pilot study, short-term efficacy and safety of fat graft enriched with Adipose-Derived Regenerative Cells (ADRC) in the treatment of Crohn’s high anal fistula was evaluated. Clinical fistula healing was achievable in 75% of cases, by a single treatment.

Hypoalbuminemia Is Associated with Increased 30-Day Complications following Rectourethral Fistula Repair: A National Surgical Quality Improvement Program Study

INTRODUCTION

We sought to assess patient risk factors for 30-day postoperative complications among men undergoing surgical management of rectourethral fistula (RUF).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all male patients who underwent RUF repair (2006-2018). Hypoalbuminemia was defined as preoperative serum albumin <3.5 gm/dL. Postoperative 30-day complications included wound infection, organ space surgical site infection, urinary tract infection, sepsis, venous thromboembolism, pneumonia, cerebrovascular accident, myocardial infarction, return to operating room and mortality. The association between pre-selected patient covariates and postoperative complications was investigated using logistic regression analysis.

RESULTS

A total of 250 patients were identified. Concurrent procedures during RUF repair were bowel diversion in 43/250 patients (17.2%), bowel resection (34/250, 13.6%), cystectomy (20/250, 8.0%) and urethroplasty (37/250, 14.8%). Overall, median age was 66.0 years (IQR 59.0-72.0), body mass index 26.6 kg/m2 (IQR 23.7-29.5) and 247/250 patients (98.8%) were functionally independent. Comorbidities included hypertension (140/250, 56.0%), smoking (55/250, 22.0%), diabetes (17/250, 6.8%), chronic obstructive pulmonary disease (11/250, 4.4%) and congestive heart failure (1/250, 0.4%). Hypoalbuminemia (<3.5 gm/dL) was present in 25/126 patients (19.8%). Overall, 51/250 patients (20.4%) experienced a complication within 30 days of surgery including wound infection (14/250, 5.6%), sepsis (13/250, 5.2%), organ space infection (11/250, 4.4%), urinary tract infection (8/250, 3.2%), venous thromboembolism (8/250, 3.2%) and mortality (5/250, 2.0%). After adjusting for covariates, hypoalbuminemia was associated with increased odds of a 30-day complication (OR 2.49, 95% CI 1.06-5.86, p=0.036).

CONCLUSIONS

Hypoalbuminemia was associated with increased odds of short-term complications after surgical management of RUF.

Predictive Risk Factors of the Conversion from Video-Assisted Treatment of Anal Fistula to Seton Fistulotomy

Background: To identify the risk factors of converting from video-assisted anal fistula treatment (VAAFT) to seton fistulotomy. Materials and Methods: A total of 180 patients registered to undergo VAAFT between January 2016 and June 2020 at the Erlonglu Hospital. Intraoperative examination of the fistula tract revealed that the patients were assigned to undergo the VAAFT operation and seton fistulotomy. Results: Among 180 patients aged 37 (±10.4) years who underwent intraoperative examination of the fistula tract, 101 completed the standard VAAFT and 79 converted to seton fistulotomy. Univariate analyses revealed that age, necrotic cavity diameter ≥1 cm, scars at the anal entrance, tissue edema, Parks classification, fistula stenosis, and fistula branches were significantly different between the VAAFT and converted groups (P < .05). Multivariate analysis revealed a significant correlation between the risk of surgery conversion and the presence of necrotic cavity with a diameter of ≥1 cm (odds ratio [OR]: 3.668, 95% confidence interval [CI]: 1.366-9.853, P = .01), scars at the anal entrance (OR: 9.462, 95% CI: 1.562-57.32, P = .014), fistula stenosis (OR: 25.14, 95% CI: 5.211-121.3, P < .001), and fistula branches (OR: 2.90, 95% CI: 1.088-7.73, P = .033). The nomogram based on the logistic model was fitted with high accuracy and area under curve of 0.793 (95% CI: 0.726-0.861). Conclusions: The independent risk factors of conversion from surgery for VAAFT to seton fistulotomy were the presence of necrotic cavity with a diameter of ≥1 cm, scars at the anal entrance, fistula stenosis, and fistula branches. The protocol of this systematic review was registered a priori in the Chinese Clinical Trial Registry (ChiCTR) under the registration number of ChiCTR1900022810.

Behcet's Syndrome resembling complex perianal Crohn's Disease

Behcet’s syndrome is a systemic inflammatory disorder that involves several organ systems and is exceptionally rare in the Western world. The diagnosis is frequently difficult as it resembles several other disease processes. A 23-year-old male with a previous presumptive diagnosis of Crohn’s disease presented to our unit with genital ulceration. This is on a background of recurrent perianal abscesses requiring surgical drainage and seton placement. He subsequently developed a complex perianal fistula extending from the rectum to the perineum and left groin. After drainage and an unsuccessful trial of biologic immunosuppressive therapy, he developed several papulopustular cutaneous lesions and oral ulcerations. The diagnostic criteria for Behcet’s syndrome was met and he was referred to a rheumatologist for ongoing management.

Radiological outcomes in perianal fistulizing Crohn's disease: A systematic review and meta-analysis

Perianal fistulas are a common and debilitating manifestation of Crohn's disease. Since the advent of biological agents, patient outcomes appear to have improved. While rates of clinical response and remission are well characterized in literature, magnetic resonance imaging (MRI) outcomes remain less so. This is despite previous studies demonstrating the persistence of fistula tracts on MRI, in spite of clinical healing, suggesting radiological markers of improvement may be more accurate. The aims of this study were to systematically review the literature for all studies reporting on MRI outcomes following biological therapy and to compare rates of radiological healing to clinical remission. A search was performed according to the Preferred Reporting Items For Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Nine articles were included, with a total sample size of 259 patients. Of these 259 patients, 47% achieved clinical remission following induction therapy and 42% following a median of 52 weeks' maintenance therapy. Out of the 259 patients, 7% achieved radiological healing in the short term and 25% in the long term. The odds ratio of MRI versus clinical healing was 0.10 (95% confidence interval [CI], 0.02–0.39) and 0.43 (95% CI, 0.26–0.71), respectively, at those corresponding time points. MRI healing of perianal fistulizing Crohn's, while arguably a more accurate assessment of treatment response, is significantly less common than clinical remission. Heterogeneity exists in the definition of radiological and clinical response, leading to variation in reported rates. Further studies, directly comparing the long‐term outcomes of patients achieving clinical remission and MRI healing are required, to better inform the role of MRI follow up in clinical practice.

Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison

Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected.

THE AIM OF THIS PAPER

The aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae.

MATERIAL AND METHODS

The results of endosonographic and magnetic resonance examinations performed in 2011-2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case.

RESULTS

In determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment - 41% and between endosonography and magnetic resonance - 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%.

CONCLUSIONS

Magnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53-67%; the highest level of agreement was noted for the assessment of branching.

Fibrin glue and transanal rectal advancement flap for high transsphincteric perianal fistulas; is there any advantage?

BACKGROUNDS AND AIM

In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results. The aim of this retrospective study was to assess the additional value of fibrin glue in combination with transanal advancement flap, compared to advancement flap alone, for the treatment of high transsphincteric fistulas of cryptoglandular origin.

MATERIALS AND METHODS

Between January 1995 and January 2006, 127 patients were operated for high perianal fistulas with an advancement flap. After exclusion of patients with inflammatory bowel disease or HIV, 80 patients remained. A consecutive series of 26 patients had an advancement flap combined with obliteration of the fistula tract with fibrin glue. Patients were matched for prior fistula surgery, and the advancement was performed identically in all patients. In the fibrin glue group, glue was installed retrogradely in the fistula tract after the advancement was completed and the fistula tract had been curetted.

RESULTS

Minimal follow-up after surgery was 13 months [median of 67 months (range, 13-127)]. The overall recurrence rate was 26% (n=21). Recurrence rates for advancement flap alone vs the combination with glue were 13% vs 56% (p=0.014) in the group without previous fistula surgery and 23% vs 41% (p=0.216) in the group with previous fistula surgery.

CONCLUSION

Obliterating the fistula tract with fibrin glue was associated with worse outcome after rectal advancement flap for high perianal fistulas.