Higher infliximab and adalimumab trough levels are associated with fistula healing in patients with fistulising perianal Crohn’s disease

BACKGROUND

Tumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn’s disease (CD), but not all patients achieve fistula healing.

AIM

To determine the correlation between perianal fistula healing and closure with infliximab and adalimumab trough levels.

METHODS

In this multicentre retrospective study conducted across four tertiary inflammatory bowel disease centres in Australia, we identified CD patients with perianal fistulae on maintenance infliximab or adalimumab who had a trough level within twelve weeks of clinical assessment. Data collected included demographics, serum infliximab and adalimumab trough levels (mg/L) within 12 wk before or after their most recent clinical assessment and concomitant medical or surgical therapy. The primary outcome was fistula healing, defined as cessation in fistula drainage. The secondary outcome was fistula closure, defined as healing and closure of all external fistula openings. Differences between patients who did or did not achieve fistula healing were compared using the chi-square test, t test or Mann-Whitney U test.

RESULTS

One hundred and fourteen patients (66 infliximab, 48 adalimumab) were included. Forty-eight (72.7%) patients on maintenance infliximab achieved fistula healing and 18 (27.3%) achieved fistula closure. Thirty-seven (77%) patients on maintenance adalimumab achieved fistula healing and 17 (35.4%) achieved fistula closure. Patients who achieved fistula healing had significantly higher infliximab and adalimumab trough levels than patients who did not [infliximab: 6.4 (3.8-9.5) vs 3.0 (0.3-6.2) mg/L, P = 0.003; adalimumab: 9.2 (6.5-12.0) vs 5.4 (2.5-8.3) mg/L, P = 0.004]. For patients on infliximab, fistula healing was associated with lower rates of detectable anti-infliximab antibodies and younger age. For patients on adalimumab, fistula healing was associated with higher rates of combination therapy with an immunomodulator. Serum trough levels for patients with and without fistula closure were not significantly different for infliximab [6.9 (4.3-10.2) vs 5.5 (2.5-8.3) mg/L, P = 0.105] or adalimumab [10.0 (6.6-12.0) vs 7.8 (4.2-10.0) mg/L, P = 0.083].

CONCLUSION

Higher maintenance infliximab and adalimumab trough levels are associated with perianal fistula healing in CD.

Efficacy and Safety of Treatment of Complex Idiopathic Fistula-in-Ano Using Autologous Centrifuged Adipose Tissue Containing Progenitor Cells: A Randomized Controlled Trial

BACKGROUND

Mesenchymal stem cells derived from adipose tissue have been successfully used to promote sphincter-saving anal fistula healing.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of the use of autologous centrifuged adipose tissue in the healing process of cryptoglandular complex anal fistulas.

DESIGN

This is a randomized controlled trial.

SETTINGS

This study was conducted at a single center.

PATIENTS

Patients with complex perianal fistulas not associated with Crohn's disease were included. Rectovaginal fistulas were not included.

INTERVENTIONS

Patients were randomly allocated to receive treatment with centrifuged adipose tissue injection (experimental group) and without injection (control group) in combination with fistula surgery.

MAIN OUTCOME MEASURES

The primary outcome was defined as the proportion of patients with complete fistula closure at 4 weeks (short-term outcome) and 6 months after surgery (long-term outcome). Healing was defined as when the external opening was closed with no perianal discharge on clinical assessment. The secondary outcome was safety that was evaluated by the analysis of adverse events up to 3 months after surgery. Pelvic MRI was performed at 3 months to assure safety and the accuracy of the clinical determination of healing. Postoperative pain, return to work/daily activities, persistent closure at 6 months, fecal incontinence, and patient satisfaction were evaluated.

RESULTS

Fifty-eight patients who received centrifuged adipose tissue injection and 58 patients who did not receive centrifuged adipose tissue injection were included in the safety and efficacy analysis. After 4 weeks, the healing rate was 63.8% in the experimental group compared with 15.5% in the control group (p < 0.001). No major adverse events were recorded. Postoperative anal pain was significantly lower in the injection group. Time taken to return to work/daily activities was significantly shorter in the experimental group (3 days) than in the control group (17 days). At 6 months, persistent closure was similar in the 2 groups (86.2% vs 81%). Fecal Incontinence Score at 6 months after surgery was identical to the preoperative score. Patient satisfaction was high in both groups.

LIMITATIONS

The absence of blinding, the lack of correlation between stem cell content, and the clinical outcome were limitations of the study.

CONCLUSIONS

Autologous centrifuged adipose tissue injection may represent a safe, efficacious, and inexpensive option for the treatment of complex fistula-in-ano. See Video Abstract at http://links.lww.com/DCR/B607.

CLINICAL TRIALS REGISTRATION

URL: https://www.clinicaltrials.gov. Identifier: NCT04326907.

EFICACIA Y SEGURIDAD DEL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA IDIOPTICA UTILIZANDO TEJIDO ADIPOSO CENTRIFUGADO AUTLOGO QUE CONTIENE CLULAS PROGENITORAS UN ENSAYO CONTROLADO ALEATORIO

ANTECEDENTES:Las células madre mesenquimales derivadas del tejido adiposo se han utilizado con éxito para promover la curación de la fístula anal con preservación de esfínter.OBJETIVO:El objetivo de este estudio fue evaluar la eficacia y seguridad del uso de tejido adiposo autólogo centrifugado en el proceso de cicatrización de fístulas anales complejas de origen criptoglandular.DISEÑO:Ensayo controlado aleatorio.ENTORNO CLÍNICO:Estudio unicéntrico.PACIENTES:Se incluyeron pacientes con fístulas perianales complejas no asociadas a Enfermedad de Crohn. No se incluyeron las fístulas rectovaginales.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente para recibir tratamiento con inyección de tejido adiposo centrifugado (grupo experimental) y sin inyección (grupo de control) en combinación con cirugía de fístula.PRINCIPALES MEDIDAS DE VALORACIÓN:El resultado primario se definió como la proporción de pacientes con cierre completo de la fístula a las 4 semanas (resultado a corto plazo) y 6 meses después de la cirugía (resultado a largo plazo). La curación se definió cuando orificio externo se cerró sin secreción perianal en la valoración clínica. El resultado secundario fue la seguridad que se evaluó mediante el análisis de los eventos adversos (EA) hasta 3 meses después de la cirugía. La resonancia magnética pélvica se realizó a los 3 meses para garantizar la seguridad y la precisión clínica de la curación. Se evaluó el dolor postoperatorio, el regreso al trabajo / actividades diarias, el cierre persistente a los 6 meses, la incontinencia fecal y la satisfacción del paciente.RESULTADOS:Cincuenta y ocho pacientes que recibieron inyección de tejido adiposo centrifugado y 58 pacientes que no recibieron inyección de tejido adiposo centrifugado se incluyeron en el análisis de seguridad y eficacia. Después de 4 semanas, la tasa de curación fue del 63,8% en el grupo experimental en comparación con el 15,5% en el grupo de control (p <0,001). No se registraron eventos adversos importantes. El dolor anal posoperatorio fue significativamente menor en el grupo de inyección. El tiempo necesario para volver al trabajo / actividades diarias fue significativamente menor en el grupo experimental (3 días) con respecto al grupo de control (17 días). A los 6 meses, el cierre persistente fue similar en los dos grupos (86,2% vs 81%). La puntuación de incontinencia fecal a los 6 meses después de la cirugía fue idéntica a la puntuación preoperatoria. La satisfacción del paciente fue muy alta en ambos grupos.LIMITACIONES:Ausencia de cegamiento, falta de correlación entre el contenido de células madre y el resultado clínico.CONCLUSIONES:La inyección de tejido adiposo centrifugado autólogo puede representar una opción segura, eficaz y económica para el tratamiento de la fístula anal compleja.Registro de ensayos clínicos: www.clinicaltrials.gov, identificador NCT04326907; No patrocinado.Consulte Video Resumen en http://links.lww.com/DCR/B607.

Leukaemia-in-ano

Fistula-in-ano is a very common surgical condition, caused by anal cryptoglandular inflammation. Most cases are idiopathic. Other causes such as Crohn's disease, trauma and malignancy are well known. Management of fistula-in-ano is largely surgical, especially if the patient is symptomatic. The goal of surgical therapy is sepsis drainage, delineate anatomy and eradicate the fistula while preserving faecal continence. Establishing the aetiology is also crucial as often a combination of specialist medical therapy is required, for example, in Crohn's disease. We report an extremely unusual case of fistula-in-ano on an elderly man with chronic lymphocytic leukaemia (CLL). Histology from the fistula track demonstrated CLL infiltration. This case, not previously reported on PubMed search, illustrates a good example of joint specialist medical (a haematologist) and surgical effort in successfully treating this symptomatic fistula-in-ano.

A comparable method to Gd-contrast enhancement in the preoperative evaluation of anal fistula

To explore a comparable method to Gd-contrast enhancement in the preoperative evaluation of anal fistula to evaluate its morphology changes.Forty-six patients with anal fistula were enrolled. Each patient acquired a 3.0T magnetic resonance imaging (MRI) routine sequence, diffusion-weighted imaging (DWI) sequence and fat suppression T1 weighted imaging (FS T1WI) contrast enhancement (CE) scanning. To record the morphology performances of the internal orifice and the fistulas on the transverse images of fat suppression T2 weighted imaging (FS T2WI), DWI, FS T2WI combined with DWI, FS T1WI Gd-CE, with the standard of the surgical pathology results. Two observers evaluated images in consensus. The conspicuity and the diagnostic performance rate were compared between the 4 imaging data sets.The consistencies of interobservers about the conspicuity scores and the diagnostic performance rates of the internal orifice and the fistula were good. The conspicuity of the internal orifice was higher for the set of FS T2WI, FS T2WI+DWI, and FS T1WI+CE than DWI. The diagnostic performance rate of the internal orifice was higher for the set of FS T2WI, FS T2WI+DWI, and FS T1WI+CE than DWI. The conspicuity of the fistula was higher for the set of FS T2WI+DWI and FS T1WI+CE than FS T2WI or DWI. There were no significantly differences between the 4 sets of FS T2WI, DWI, FS T2WI+DWI, and FS T1WI+CE in the diagnostic performance rate of the fistula.The set of FS T2WI combined with DWI was comparable to FS T1WI CE in evaluation of anal fistula morphology changes.

Online training on how to diagnose anoperineal lesions of Crohn's disease: Do pictures matter? A nationwide randomized study

Any gastroenterologist must be trained to properly diagnose anoperineal lesions in patients with Crohn's disease (APLOC). The aim of this study was to establish whether adding pictures would improve teaching effectiveness of the diagnosis of APLOC to French gastroenterology trainees.

METHOD

Trainees were asked to answer a first web-based survey consisting of evaluating 12 pictures of APLOC with a closed answer questionnaire. They were then randomized in 2 groups. Group A received an online teaching with typical pictures and APLOC definitions and group B definitions only. Trainees were asked again seven days later to answer a second survey with 12 other pictures of APLOC and 14 experts also answered this survey. Diagnostic scores were expressed in %. The primary endpoint was the comparison of the score of survey 2 between the two groups of trainees. Secondary endpoints were to compare results of survey 2 between trainees of both groups and experts, and assess diagnosis of each lesion.

RESULTS

Two hundred fourty eight trainees among 465 answered survey 1, and 195 survey 2. The diagnostic score was 71.9% for groups A and B and 74.6% for experts (differences NS). After training diagnosis of ulceration was 72% for group A and 72.9% for group B, fistulae 85.2% versus 85.8%, erythema 44.1% vs. 55.6%, anoperineal scars 67.5% vs. 65.6%, and abscess 100% (differences NS).

CONCLUSION

There was no difference between the two teaching methods. Further research should be performed aiming at improving teaching material and quotation baremes.

Mesenchymal Stem Cells for Perianal Crohn's Disease

Perianal fistulizing Crohn’s disease (PFCD) is associated with significant morbidity and might negatively impact the quality of life of CD patients. In the last two decades, the management of PFCD has evolved in terms of the multidisciplinary approach involving gastroenterologists and colorectal surgeons. However, the highest fistula healing rates, even combining surgical and anti-TNF agents, reaches 50% of treated patients. More recently, the administration of mesenchymal stem cells (MSCs) have shown notable promising results in the treatment of PFCD. The aim of this review is to describe the rationale and the possible mechanism of action of MSC application for PFCD and the most recent results of randomized clinical trials. Furthermore, the unmet needs of the current administration process and the expected next steps to improve the outcomes will be addressed.

Diffusion tensor imaging for evaluating perianal fistula: Feasibility study

To explore the feasibility of using diffusion tensor imaging (DTI) in the diagnosis of anal fistula and evaluating its activity.Thirty-four patients with perianal fistulas were examined with DTI on a 3.0 T magnetic resonance imaging (MRI) before undergoing surgery. Based on the surgery requirement and preoperative examinations, the lesions fell into 2 groups: the positive inflammation activity (PIA) group and the negative inflammation activity (NIA) group. Each lesion was divided into 3 regions of interest (ROIs) (i.e., the fistula area, edema area, and distant normal-appearing area). Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated and analyzed.There were statistically significant differences in FA and ADC values of the fistula area, edema area, and distant normal-appearing area. The FA values of the fistula area, edema area, and distant normal-appearing area in PIA were 0.134 ± 0.046, 0.225 ± 0.060, 0.343 ± 0.070, respectively. The ADC values (×10 mm/s) of the fistula area, edema area, and distant normal-appearing area in PIA were 0.979 ± 0.441, 1.542 ± 0.274, 1.864 ± 0.336, respectively. The FA values of the fistula area, edema area, and distant normal-appearing area in NIA were 0.183 ± 0.057, 0.286 ± 0.059, 0.382 ± 0.084, respectively. The ADC values (×10 mm/s) of the fistula area, edema area, and distant normal-appearing area in NIA were 1.393 ± 0.256, 1.518 ± 0.274, 1.703 ± 0.432, respectively. Regarding the activity, the FA and ADC values of the PIA group were lower than those of the NIA group in the fistula area, and the differences were statistically significant (P = .009, .004). The FA values of the edema area in the PIA group were lower than those in the NIA group, and the difference was statistically significant. The ADC values of the edema area, and both the FA and ADC values of the distant normal-appearing area all exhibited no statistically significant differences between the 2 groups.DTI parameters may reflect microstructures of perianal fiatulas via quantitative information. FA and ADC values were instrumental in evaluating the activity of perianal fistulas.

Experimental porcine model of complex fistula-in-ano

AIM

To establish and evaluate an experimental porcine model of fistula-in-ano.

METHODS

Twelve healthy pigs were randomly divided into two groups. Under general anesthesia, the experimental group underwent rubber band ligation surgery, and the control group underwent an artificial damage technique. Clinical magnetic resonance imaging (MRI) and histopathological evaluation were performed on the 38^th d and 48^th d after surgery in both groups, respectively.

RESULTS

There were no significant differences between the experimental group and the control group in general characteristics such as body weight, gender, and the number of fistula (P > 0.05). In the experimental group, 15 fistulas were confirmed clinically, 13 complex fistulas were confirmed by MRI, and 11 complex fistulas were confirmed by histopathology. The success rate in the porcine complex fistula model establishment was 83.33%. Among the 18 fistulas in the control group, 5 fistulas were confirmed clinically, 4 complex fistulas were confirmed by MRI, and 3 fistulas were confirmed by histopathology. The success rate in the porcine fistula model establishment was 27.78%. Thus, the success rate of the rubber band ligation group was significantly higher than the control group (P < 0.05).

CONCLUSION

Rubber band ligation is a stable and reliable method to establish complex fistula-in-ano models. Large animal models of complex anal fistulas can be used for the diagnosis and treatment of anal fistulas.

Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn's disease: a phase 3 randomised, double-blind controlled trial

BACKGROUND

Complex perianal fistulas in Crohn's disease are challenging to treat. Allogeneic, expanded, adipose-derived stem cells (Cx601) are a promising new therapeutic approach. We aimed to assess the safety and efficacy of Cx601 for treatment-refractory complex perianal fistulas in patients with Crohn's disease.

METHODS

We did this randomised, double-blind, parallel-group, placebo-controlled study at 49 hospitals in seven European countries and Israel from July 6, 2012, to July 27, 2015. Adult patients (≥18 years) with Crohn's disease and treatment-refractory, draining complex perianal fistulas were randomly assigned (1:1) using a pre-established randomisation list to a single intralesional injection of 120 million Cx601 cells or 24 mL saline solution (placebo), with stratification according to concomitant baseline treatment. Treatment was administered by an unmasked surgeon, with a masked gastroenterologist and radiologist assessing the therapeutic effect. The primary endpoint was combined remission at week 24 (ie, clinical assessment of closure of all treated external openings that were draining at baseline, and absence of collections >2 cm of the treated perianal fistulas confirmed by masked central MRI). Efficacy was assessed in the intention-to-treat (ITT) and modified ITT populations; safety was assessed in the safety population. This study is registered with ClinicalTrials.gov, number NCT01541579.

FINDINGS

212 patients were randomly assigned: 107 to Cx601 and 105 to placebo. A significantly greater proportion of patients treated with Cx601 versus placebo achieved combined remission in the ITT (53 of 107 [50%] vs 36 of 105 [34%]; difference 15·2%, 97·5% CI 0·2-30·3; p=0·024) and modified ITT populations (53 of 103 [51%] vs 36 of 101 [36%]; 15·8%, 0·5-31·2; p=0·021). 18 (17%) of 103 patients in the Cx601 group versus 30 (29%) of 103 in the placebo group experienced treatment-related adverse events, the most common of which were anal abscess (six in the Cx601 group vs nine in the placebo group) and proctalgia (five vs nine).

INTERPRETATION

Cx601 is an effective and safe treatment for complex perianal fistulas in patients with Crohn's disease who did not respond to conventional or biological treatments, or both.

FUNDING

TiGenix.

Results of the Fifth Scientific Workshop of the ECCO (II): Pathophysiology of Perianal Fistulizing Disease

The fifth scientific workshop of the European Crohn's and Colitis Organization (ECCO) focused on the relevance of fistulas to the disease course of patients with Crohn's disease (CD). The objectives were to reach a better understanding of the pathophysiological mechanisms underlying the formation of CD fistulas; to identify future topics in fistula research that could provide insights into pathogenesis; to develop novel therapeutic approaches; and to review current therapeutic strategies (with clarification of existing approaches to prevention, diagnosis and treatment). The results of the workshop are presented in two separate manuscripts. This manuscript describes current state-of-the-art knowledge about fistula pathogenesis, including the roles of epithelial-to-mesenchymal transition and cytokine matrix remodelling enzymes, and highlights the common association between fistulas and stenosis in CD. The review also considers the possible roles that genetic predisposition and intestinal microbiota play in fistula development. Finally, it proposes future directions and needs for fistula research that might substantially increase our understanding of this complex condition and help unravel novel therapeutic strategies and specific targets for treatment. Overall, it aims to highlight unanswered questions in fistula research and to provide a framework for future research work.

[APPLICATION OF FISTULA PLUG WITH THE FIBRIN ADHESIVE IN TREATMENT OF RECTAL FISTULAS]

Results of surgical treatment of 21 patients, suffering high transsphincteric and extrasphincteric rectal fistulas, were studied. In patients of Group I the fistula passage was closed, using fistula plug obturator; and in patients of Group II--by the same, but preprocessed by fibrin adhesive. The fistula aperture germeticity, prophylaxis of rude cicatrices development in operative wound zone, promotion of better fixation of bioplastic material were guaranteed, using fistula plug obturator with preprocessing, using fibrin adhesive.

[Sexual dysfunction is frequent in patients with anal fistulas and anal fissures]

Anal fistulas and fissures are frequent disorders. Affected patients may have significant psychosocial and sexual dysfunction. A few studies have investigated patients with anal fissures and fistulas with regard to sexual dysfunction. These studies showed a significant degree of sexual dysfunction among the affected patients. Data are surprisingly limited in this field. More studies are needed to describe this issue and to define a successful treatment for these patients.

A modified pathway of perineal packing in patients requiring surgery for perineal fistulas with extensive perineal involvement

AIM

To describe a method to manage complex perianal fistulas with extensive perineal involvement, allowing avoidance of exposure of wide wounds and repeated procedures.

MATERIAL OF STUDY

All patients presenting with perianal fistulas extensively spreading to the perineum requiring surgery between January 2010 and December 2012 were enrolled in the present study. Diabetic patients and those with active abdominal Crohn's disease (CD) were ruled out from evaluation. After clinical and radiological assessment, patients underwent exploration under anaesthesia, and the conventional procedures were completed with at least one wide perineal fistulotomy, managed with "perineal packing" with gauzes. Patients were followed-up for complications and healing of fistulas.

RESULTS

Eight patients (3 males, mean age 38 ± 5.1 years) were enrolled in the present study. Four patients had CD, two had Hidradenitis suppurativa, and two had idiopathic fistula-in-ano. All but two patients were not required to stay overnight. Gauzes were removed in outpatient settings. One patient had bleeding requiring coagulation with electroscalpel. One patient needed to receive analgesics and four wore pads in the maturation period. No sepsis was observed. Mean time to healing was 21.5 ± 3.2 days; mean time off-work was 2 ± 1.3 days. Patients reported no significant impairment of leisure activities. No recurrences were observed at a mean follow-up of 16.4 ± 2.1 months. Major complications were not observed.

DISCUSSION

All patients achieved complete healing of the perineal tracks, without significant impairment of social function and need for further surgical treatments. Patients were safely discharged and promptly returned to work or leisure activities.

CONCLUSIONS

Our data suggest that the procedure is safe and effective in selected patients with extensive perineal involvement.

Mucinous adenocarcinoma associated with a chronic perianal fistula - a review of cases from a single institution

PURPOSE

The purpose of this study was to evaluate the clinicopathological features of mucinous adenocarcinoma associated with perianal fistulas (MAF), to assess the importance of preoperative MRI analysis, and to determine the optimal surgery.

METHODS

We performed a retrospective analysis of the data from seven patients with MAF treated at our hospital between 2000 and 2013, and herein discuss the importance of preoperative magnetic resonance imaging (MRI) and of radical surgery.

RESULTS

The male to female ratio was 5:2, and the mean age of the patients was 63 years old (28-70). The median duration of chronic fistulation was 16 years (5-40). The tumor extension was classified as II+III+IV in five patients and as II+III in 2 patients according to the Sumikoshi classification, as determned by pelvic MRI. The performed surgeries were 3 abdominoperineal resections with sacral resection and 4 pelvic exenterations with sacral resection. Two local recurrences developed in patients with R1 resection, and 1 distant metastasis occurred in 1 patient with R0 resection.

CONCLUSION

For patients with MAF, a curative surgical resection is the only definitive treatment that can be expected to provide a good prognosis. The application of the Sumikoshi classification using MRI may provide a precise assessment of the extension of MAF, which can allow the appropriate surgery to be selected for the patients with MAF.

[Tactic of surgical treatment of complex rectal fistula]

The experience of the examination and treatment of 646 patients for different forms of complex rectal fistula (CRF) summarized. A working classification of the CRF with regard to their complication was developed and implemented. A differentiated approach has allowed greater use sphincter-preserving methods to improve functional outcome, quality of life, reduce the duration of the disability period and frequency of patients disability.

[Efficacy of application of sphincter-preserving surgeries in the treatment of complex rectal fistulas]

The methods of sphincterpreserving operative interventions, and a principally new algorithm of treatment was elaborated for enhancing of the treatment efficacy in patients, suffering complex rectal fistulas. There were examined 291 patients, ageing 20 - 62 yrs old, all of whom operated on in Odessa Rural Clinical Hospital in 2003 - 2014 yrs for complex transsphincteric and extrasphincteric rectal fistulas. In 120 patients (I clinical group) a ligature method in accordance to standard procedure was applied; in 108 (II group)--a plastic method with transposition of mucosa-submucosal flap in accordance to original procedure; in 63 (III group)--a method of intrasphincteric ligature of complex rectal fistulas. Application of plastic method of intrasphincteric ligature of complex rectal fistulas have permitted to omit the anal incontinence, to reduce the unemployment period in 2 - 2.5 times. But a recurrence rate after sphincterpreserving operations is certainly bigger: while a ligature method application--by 5%, of a plastic one--11.1%, of intrasphincteric ligature--9.2%. Application of elaborated algorithm for the patients treatment for complex rectal fistulas have promoted preservation of high quality of life in 96.3% patients, as well as reduction of rate of their disabling.

[Surgical treatment of patients, suffering Crohn's disease]

In surgical clinic of Zakarpattya's Regional Clinic n. a. Andriy Novak (City of Uzhgorod) 43 patients were observed for complicated Crohn's disease (CD), in whom 79 operations were performed, including in 1 patient--8 interventions, in 10--on 3, in 5--on 2, and in others--on one. Not depending, that the recurrence occurrence rate is definitely high, at average in every 10 yrs for the patients reoperation is indicated, the surgical treatment, conducted in accordance to absolute indications, is considered as highly effective and a sole correct approach for elimination of severe complications of CD, what provides the life span enhancement and its quality rising. Absolute indications for surgical treatment of acute complications of CD are following: perforation, peritonitis, ileus, phlegmon, abdominal and retroabdominal abscesses, profuse bleeding, toxic dilatation of large bowel. Chronic complications of CD--inflammatory infiltrates with the internal organs compression; internal and external fistulas; intestinal stricture with signs of obturation ileus; recurrent paraproctitis; extrasphincteric fistulas; destruction of muscular carcass of anal sphincter.

Amoebic anal fistula: new insight into an old disease

A 67-year-old gentleman underwent fistulectomy for low trans-sphincteric anal fistula along with curettage for an associated abscess extending proximally for half a centimeter into the intersphincteric plane. The roof of the cavity became clearly visible after satisfactory culmination of the surgical procedure. Histopathological examination of the fistulous tract and the curetted granulation tissue revealed presence of multiple trophozoites of Entamoeba histolytica exhibiting erythrophagocytosis in the background of mixed inflammatory infiltrate. This case report provides the outlook that yields the novel insight into the possible role of Entamoeba histolytica in the pathogenesis and persistence of the fistulous tract.

[Results of surgical rehabilitation of patients in the presence of external colonic fistula in conditions of district hospital]

Results of treatment of 102 patients for a variety of injuries and surgical diseases of the colon, who performed the intervention, culminating in the formation of the external colonic fistula (ECF) were analyzed. After reconstructive and restorative surgery for ECF, all patients were alive. Postoperative complications occurred in 15 (20.8%) patients, including intraabdominale--in 2 (2.8%). The optimal timing of surgical rehabilitation and volume reduction or reconstructive surgery in patients over the ECF should be determined strictly individual basis, taking into account the severity and nature of the illness or injury, which required imposition of an stoma, the severity of postoperative scar and local inflammatory processes in the abdominal cavity, in laparotomic wound and fistula. Performing simultaneous operations in the surgical rehabilitation of patients with ECF practically does not increase the risk of postoperative complications.

Squamous cell carcinoma associated anal fistulas in Crohn's disease unique case report with literature review

Squamous cell carcinoma arising from perineal fistula in patients with Crohn's disease (CD) is a rare entity, with few reported cases in the literature making its clinical characterization troublesome. The outcome is poor following operative treatment as the malignancy of chronic perineal fistula in Crohn's disease is usually overlooked and tardily diagnosed. We present a unique case of a 47-year-old man with a 20-year history of chronic perineal fistula that was diagnosed with extensive perineal squamous cell carcinoma extending down to the right thigh. Computer tomography showed locally advanced disease with inguinal and lung metastasis. Treatment was consisted of diverting colostomy and palliative care. The patient died 3 months later. The clinical data and clinicopathological features of reported cases in the literature were reviewed.

Perianal adenocarcinoma associated with anal fistula: a report of 11 cases in a single institution focusing on treatment and literature review

BACKGROUND/AIMS

Perianal adenocarcinoma associated with anal fistula is a rare disease with a poor prognosis. The relatively small number of patients with this disease has led to a lack of any consensus regarding diagnosis and appropriate treatment. The purpose of this study was to present our experience of 11 cases of this disease, and to highlight its clinical features, treatments and outcomes.

METHODOLOGY

The patients were divided into three groups according to the modality of treatment. Four patients received surgical resection without preoperative therapy (operation group), 3 patients were treated with radiotherapy prior to surgery (RT group), and 4 were treated with combined chemoradiation therapy prior to surgery (CRT group).

RESULTS

The resection stump was pathologically negative for cancer in 6 (85.7%) patients in RT or CRT group, and 3 of 6 are alive with no evidence of disease recurrence. However, the resection stump was negative in only 1 (25%) patient in the operation group. Moreover, among the patients who underwent neoadjuvant RT/CRT and abdominoperineal resection with a cancer-free resection stump, 2 patients with postoperative adjuvant therapy had no recurrence of disease.

CONCLUSIONS

Multimodality therapy including neoadjuvant RT or CRT and adjuvant chemotherapy is considered to be effective for treatment of this disease.

Primary and secondary adenocarcinomas associated with anal fistulae

PURPOSE

The purpose of this study was to evaluate the clinical features, pathology, and etiology of adenocarcinoma in patients with anal fistulae.

METHODS

We identified seven patients diagnosed with adenocarcinoma associated with anal fistulae from a retrospective chart review.

RESULTS

Five patients were diagnosed with primary adenocarcinoma associated with anal fistulae. Two patients were diagnosed with secondary adenocarcinoma associated with anal fistulae originating from rectal cancer on the proximal side. The primary adenocarcinomas included cancers arising from long-standing anal fistulae fulfilling established diagnostic criteria in two patients, and cancer arising from short-duration anal fistulae in three patients. Excision of the fistula was performed based on the initial diagnosis of the anal fistula for all five patients. Increased suspicion of cancer was due to the existence of gelatinous material in the anal fistula in three patients and induration in the resected specimens in two patients. The etiologies of the secondary adenocarcinomas associated with anal fistulae included implantation in the anal fistula from rectal cancer and fistula formation originating due to the progression of rectal cancer.

CONCLUSION

Anal fistulae are commonly seen in the coloproctology clinic, but special attention to similar conditions associated with malignant disease is needed.

[Significance of nontraumatic anal sphincter relaxation for the success of plastic and miniinvasive interventions in coloproctology]

The investigation objective was to estimate the role of nontraumatic anal sphincter (AS) stretching, as a leading factor of success in minimally invasive and/or plastic proctological interventions. One-centre randomized investigation was performed in 83 patients: In 22 of them the AS fissura was revealed (in 16), suprasphincteric fistula (in 3) and coexistent rectocele 2-3 Ap (according to POP-Q classification) with thinning of the AS anterior segment, the degree III hemorrhoids and anterior AS fissure presence. Ninety units of botulotoxin preparation (Disport) were injected between internal and external AS portions 5-15 days preoperatively. The treatment results without botulotoxin injection were compared retrospectively. After botulotoxin injection performance the AS spasm elimination was noted, leading to the pain subsiding promotion before and postoperatively in all the patients observed. The spasm elimination have permitted to escape the anal high fistula recurrence as a result of the mucosal flap shift after intraluminal closure of the fistula or because of the fistula intermuscular electrowelding "suture" rupture, also have guaranteed the plastic sutures on AS, even while the stage II-III rectocele presence, not depending of performance of its simultant surgica correction.

[Surgical treatment of anal fistulas in Crohn's disease]

The treatment of transsphincteric anal fistulas in Crohn's disease is a balance between the elimination of the sepsis and the functional outcome. Loose setons can be used as a preoperative drainage or chronic treatment. Fibrin glue and the anal fistula plug are methods with excellent functional outcomes, but the success rate varies. The endorectal advancement flap is considered to be the gold standard. Ligation of the intersphincteric fistula tract is promising. Proctectomy or proctocolectomy in combination with transposition flaps may be necessary. A success rate of 66-70% has been reported.

[Nonspecific granulomatous inflammation in Crohn's disease]

A comparative morphological study of intestinal wall tissues in such chronic colonic diseases, such as Crohn's disease, ulcerative colitis, and catarrhal rectal fistulas, allows the formation of giant cells of foreign bodies and their granulomas and sarcoid-type ones to be nonspecific. Their spread through and outside the colon is due to the migration of foreign bodies along the lymphatic vessels. Foreign inclusions of different shapes and structures in the cytoplasm of giant cells suggest that the colon contains the multiple particles of varying antigenic nature, which induce a unified morphological response medicated by innate and adaptive immunity cells. Consequently, the universally accepted substantiation of the diagnosis of Crohn's disease by the presence of granulomas is unconvincing.

Clinical characteristics of non-perianal fistulating Crohn's disease in China: a single-center experience of 184 cases

BACKGROUND

There is little information of non-perianal fistulating Crohn's disease in the consensus published by the European Crohn's and Colitis Organization in 2006 and 2010. This study was designed to demonstrate the clinical characteristics of non-perianal fistulating Crohn's disease among homogenous Chinese population.

METHODS

One-hundred-and-eighty-four patients were retrospectively collected. All of these patients were diagnosed of Crohn's disease between February 2001 and April 2011.

RESULTS

The male-to-female ratio was 2.7:1. The most common symptoms at onset were abdominal pain (88.0%), diarrhea (34.7%), and fever (28.3%). The most common disease location and behavior at diagnosis were small bowel (56.0%) and penetrating (51.6%). Among 324 non-perianal fistulae, the most common types were ileocolonic anastomotic (30.9%), terminal ileocutaneous (19.7%), and enteroenteric anastomotic (11.4%). One-hundred-and-thirty- eight (75.0%) patients received antibiotics, and β-lactam (85.5%) and metronidazole (67.4%) are most frequently used. One-hundred-and-seventy-eight (96.7%) patients suffered 514 surgical operations, and the cumulative surgical rates after 1, 3, and 5 years were 38.0%, 52.2%, and 58.7% respectively. Nine patients died during the follow-up period, and the cumulative survival rates after 1, 3, and 5 years were 97.8%, 96.7%, and 96.2% respectively.

CONCLUSIONS

This study displayed the clinical characteristics of non-perianal fistulating Crohn's disease in our center. Large population-based studies are required for further investigation in China.

Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage

BACKGROUND

The ligation of intersphincteric fistula tract (LIFT) is a relatively new surgical technique for treating complex anorectal fistulas.

METHODS

LIFT was compared with anorectal advancement flap management (ARAF) of complex anorectal fistulas requiring previous seton drainage. Crohn's patients were excluded. Patients with no confirmed recurrent sepsis after 6 months were randomized to day surgery performance of LIFT (25; 17 male) or ARAF (14; 10 male) with removal of the seton. Outcome measures included recurrences, surgical time, complications, hospital readmissions, and fecal incontinence.

RESULTS

LIFT was 32.5 minutes shorter than ARAF (P < .001). Complications were similar, with no hospital readmissions. Return to normal activities was 1 week for LIFT patients, 2 weeks for ARAF patients (P = .016). At 19 months there were 3 recurrences (2 in the LIFT group). One ARAF patient had minor incontinence.

CONCLUSIONS

The LIFT procedure was simple, safe, shorter, and patients returned to work earlier. All patients had preliminary seton drainage, possibly contributing to the low recurrence rates.

Long-term follow-up of patients undergoing adipose-derived adult stem cell administration to treat complex perianal fistulas

PURPOSE

In patients with perianal fistulas, administration of adult stem cells (ASCs) derived from liposuction samples has proved a promising technique in a preceding phase II trial. We aimed to extend follow-up of these patients with this retrospective study.

METHOD

Patients who had received at least one dose of treatment (ASCs plus fibrin glue or fibrin glue alone) were included. Adverse events notified since the end of the phase II study were recorded. Clinical and magnetic resonance imaging (MRI) criteria were used to determine whether recurrence of the healed fistula had occurred.

RESULTS

Data were available for 21 out of 24 patients treated with ASCs plus fibrin glue and 13 out of 25 patients treated with fibrin glue in the phase II study. Follow-up lasted a mean of 38.0 and 42.6 months, respectively. Two adverse events unrelated to the original treatment were reported, one in each group. There were no reports of anal incontinence associated with the procedure. Of the 12 patients treated with ASCs plus fibrin glue who were included in the retrospective follow-up in the complete closure group, only 7 remained free of recurrence. MRI was done in 31 patients. No relationship was detected between MRI results and the clinical fistula status, independent of the treatment received.

CONCLUSIONS

Long-term follow-up reaffirmed the very good safety profile of the treatment. Nevertheless, a low proportion of the stem cell-treated patients with closure after the procedure remained free of recurrence after more than 3 years of follow-up.

[Identification of internal fistolous orifice: evolution of methylene blue technique with a mini-probe]

INTRODUCTION

Often perianal fistulas can be difficult typing and traditional anatomical classifications do not help the surgeon in accurate diagnosis of the fistula as an outpatient procedure and therefore does not allow a timely surgical currettage. The aim of our study was to introduce in the management of anal fistulas performed on an outpatient injection with methylene blue of the fistula through a small polyethylene catheter in order to detect in real time the internal opening of the fistula and drive so the next currettage surgery.

MATERIALS AND METHODS

A total of 50 consecutive patients 21 female and 29 male, relating to our clinic with symptoms suggestive of colon proctology perianal fistula, aged between 36 and 69 years were selected for our study. After running the news-gathering medical history, physical examination, digital examination through examination anoscope, using a polyethylene catheter in a small scale, of methylene blue was injected through the external fistula orifice looking inside the spreading of liquid. Subsequently, the patient was started on specillazione currettage and possible surgery.

RESULTS

62 outpatients were treated intramural fistulas, diagnosed with the injection technique with methylene blue running always probing and practiced a wide dish made of the mucosa, submucosa and circular muscle layer of the internal drainage with sphincterotomy. In particular, the technique injection of methylene blue was sufficient to diagnose 42 out of 62 cases examined (67.7%). In the remaining 20 cases it was necessary to integrate diagnosis with MRI-defecates on the complexity of fistulas (10 horseshoe, 6 trans sphincteric and 4 intersphincteric.

CONCLUSIONS

Methylene blue injection is a low-cost screening technique, simple to perform on an outpatient basis and in the case of suprasphincteric fistulas also a simple diagnostic technique is sufficient to allow the closure of the fistula.

[A case of carcinoma associated with anal fistula resected after preoperative chemoradiotherapy]

A 66-year-old man with a 39-year history of anal fistula was admitted to our hospital for anal pain and bleeding. Fistulectomy was carried out for anal fistula. Histological examination of the specimen revealed carcinoma associated with anal fistula. A computed tomography showed that the tumor had invaded the prostate. Therefore, preoperative chemoradiotherapy(S-1 plus radiation 40 Gy/body)for locally advanced cancer was performed. Magnetic resonance imaging showed that the boundary between the tumor and the prostate was unclear, but we performed an abdominoperineal resection and the prostate was fully preserved. Histopathologically, no cancer cell existed on the surgical margin. The histological effect of chemoradiotherapy was judged as grade 2. This case suggested that surgical treatment combined with preoperative chemoradiotherapy may be effective for locally advanced carcinoma associated with anal fistula, in which preservation of adjacent organs is considered to be difficult.

[Surgical tactics in acute paraproctitis]

Individualized tactics of radical surgical treatment, applied in 100 patients, suffering an acute paraproctitis, was presented. Performing comparative estimation of the treatment results in 110 patients, in whom the conventional surgical approaches were applied, there was established, that an active surgical tactics secures essential reduction of the patients stationary treatment duration, the rate of the disease recurrence occurrence and transformation into the chronic illness.

[Results of one-stage reconstruction of anal sphincter in surgical treatment of fistulas-in-ano combined with fecal incontinence]

The investigation included 20 patients. Mean index of the severity of incontinence before operation by the Wexner scale was 9.3+/-2.4 scores. After radical dissection of the fistula and sphincter plasty in 7 patients (the first group) the wound of the rectum mucosa was sutured in longitudinal direction, in 13 patients (the second group) the rectum wall graft was brought down to the edge of the created anal canal. Uncomplicated post-operative period was noted in 15 (75%) patients. Suppuration of the wound developed in 3 (42.9%) patients of the first group and in 2 (15.3%) patients of the second group. The index of incontinence severity decreased to 2.4+/-1.1% scores (reduction of 4.5 scores in the first group and 7.7 scores in the second group).

Rectoprostatic fistula: unusual presentation of a prostatic abscess

OBJECTIVE

To present the case and iconography of a rectoprostatic fistula as a form of presentation of a prostatic abscess and to review the literature on the diagnosis and treatment of this pathology.

METHODS

69-year-old male with multiple pathologic conditions who presents an orifice in the prostatic fossa on digital rectal examination in the scenario of a urinary tract infection with fever. CT scan and colonoscopy showed a prostatic abscess fistulizing to rectum.

RESULTS

Due to spontaneous drainage of the abscess, conservative treatment with intravenous fluid therapy and antibiotics was chosen.

CONCLUSIONS

Prostatic abscess is often difficult to diagnose because of its low prevalence and unspecific symptomatology. Since the introduction of antibiotics, cases in which abscess fistulas or opens spontaneously to neighboring structures like urethra or rectum have decreased.

Nonfistulizing perianal Crohn's disease: clinical features, epidemiology, and treatment

Nonfistulizing perianal lesions, including ulcerations, strictures, and anal carcinoma, are frequently observed in Crohn's disease. Their clinical course remains poorly known. The management of these lesions is difficult because none of the treatments used is evidence-based. Ulcerations may be symptomatic in up to 85% of patients. Most ulcerations heal spontaneously but may also progress to anal stenosis or fistula/abscess. Topical treatments only improve symptoms, while complete healing can occur in patients with perianal ulcerations receiving infliximab therapy. Half of all patients with anal strictures will require permanent fecal diversion. Dilatation for symptomatic strictures should be performed on a highly selective basis in the absence of active rectal disease in order to avoid infectious complications. Anorectal strictures associated with rectal lesions should first be managed with medical therapy. Skin tags are usually painless and may hide other perianal lesions. Anal cancer is uncommon. Its treatment is similar to that recommended for anal cancer occurring in non-Crohn's disease patients. After reviewing the classification, clinical features, and epidemiology of each type of nonfistulizing perianal lesion (ulceration, stricture, skin tags, and anal cancer), we discuss the efficacy of medical treatment and surgery. This review article may help physicians in decision-making when managing potentially disabling lesions.

Clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing Crohn's disease: when and how were the seton drains removed?

BACKGROUND/AIMS

Perianal fistulas are often found in patients with Crohn's Disease (CD), however, the complete management of such fistulas tends to be difficult. The aim of this study is to critically evaluate the clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing CD.

METHODOLOGY

Fourteen patients (9 males, 5 females) were evaluated for perianal fistulizing CD with the seton and infliximab therapy. Almost all patients were examined for the presence of either an abscess or fistulas by computed tomography (CT) and/or Magnetic Resonance Imaging (MRI) in addition to their physical findings. Seton placement was performed under general anesthesia, following the administration of inflixmab at a dose of 5 mg/kg for weeks 0, 2 and 6, and then about every 8 weeks as a maintenance therapy.

RESULTS

For all patients average number of inserted drains was 4.5 and the average number of infliximab infusions was 9.4 times. The mean follow-up period was 12.1 months. A redness and/or swelling in perianal lesion were seen in 12 patients, moreover, pus discharge was seen in 7 patients, and serous exudate was seen in 7 patients. After the administration of these treatments, a reversal of the redness and/or swelling was seen in the exudate and a wet-to-dry wound change was found in all patients. Furthermore, the seton drains were completely removed in 11 patients. In most patients, seton drains were completely removed after 5 rounds of infliximab infusion. Following the removal of the seton drains from all the patients, they reported their post-treatment health and well-being to be good while also reporting a good quality of life (QOL). In addition, no serious adverse events were observed.

CONCLUSIONS

The combined seton placement and infliximab maintenance therapy for perianal fistulizing CD was therefore found to be effective in terms of fistula closure and the removal of seton drains. This treatment modality is therefore considered to be a safe clinical procedure which improves the QOL in patients with CD.

[Temporary total fecal diversion--ultimate solution for complex recurrent anal fistula]

Anal fistula is a frequent disease, but complex fistulae are relatively uncommon. The treatment for this pathology remains debated all over the world, and in cases of complex fistulae represents a challenge. We present a 55 years old male, operated more than 40 times in the last 15 years for perianal recurrent fistulas and abscesses. The fistula has had a progressive evolution despite all kind of surgery and has extended finally to entire perineal and gluteal region; more than 30 orifices were founded on skin surface and many internal anorectal orifices as well. The patient is weakened, anemic, in chronic sepsis. As a last resort, we decided to perform a terminal fecal diverting stoma at the level of sigmoid colon, with closure of distal end. There were subsequent operations necessary to resolve perineal and gluteal disease: extensive excisions of altered tissues, various full-thickness skin grafts and covering flaps. After 12 months the perineal region was clean, so remaking of colic continuity was possible. Continuous follow-up until 12 months revealed no sign of recurrence. We conclude that temporary total fecal diversion followed by wide excisions of perianal fistulous tissues represents an ultimate solution to complex recurrent perianal fistula, with good results at least in our case.

Fecal diversion in perirectal fistulizing Crohn's disease is an underutilized and potentially temporary means of successful treatment

The purpose of this study was to determine the outcome of patients treated with fecal diversion for perirectal fistulizing Crohn's disease. Thirty-nine patients were identified and followed for an average of 60 months. Patients were divided into two groups based on surgical treatment: local surgical treatment only and fecal diversion in addition to local surgical therapy. Thirteen patients (33%) underwent fecal diversion due to the severity of their disease. Eleven of these patients (85%) had complete resolution of their fistulas and only two (15%) required proctectomy. In contrast, only five out of 26 patients (19%) who underwent local surgical procedures alone had complete perirectal disease resolution. Intestinal continuity was restored in six patients (46%) and three of these patients (50%) remained disease free. The remaining three patients had disease recurrence, which required additional local procedures in one patient (17%), but with eventual resolution; the other two patients (33%) necessitated rediversion. Our data suggest that fecal diversion is a viable treatment option for severe perirectal fistulizing Crohn's disease and may be associated with a higher rate of resolution than local surgical treatment alone. In addition, we demonstrate a higher rate of successful intestinal continuity restoration than is typically reported.

Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial

PURPOSE

The feasibility and safety of stem cell-based therapy with expanded adipose-derived stem cells (ASCs) has been investigated in a phase I clinical trial. The present study was designed as a phase II multicenter, randomized controlled trial to further investigate the effectiveness and safety of ASCs in the treatment of complex perianal fistulas.

METHODS

Patients with complex perianal fistulas (cryptoglandular origin, n = 35; associated with Crohn's disease, n = 14) were randomly assigned to intralesional treatment with fibrin glue or fibrin glue plus 20 million ASCs. Fistula healing and quality of life (SF-12 questionnaire) were evaluated at eight weeks and one year. If healing was not seen at eight weeks, a second dose of fibrin glue or fibrin glue plus 40 million ASCs was administered.

RESULTS

Fistula healing was observed in 17 (71 percent) of 24 patients who received ASCs in addition to fibrin glue compared with 4 (16 percent) of 25 patients who received fibrin glue alone (relative risk for healing, 4.43; confidence interval, 1.74-11.27); P < 0.001). The proportion of patients with healing was similar in Crohn's and non-Crohn's subgroups. ASCs were also more effective than fibrin glue alone in patients with a suprasphincteric fistulous tract (P = 0.001). Quality of life scores were higher in patients who received ASCs than in those who received fibrin glue alone. At one year follow-up, the recurrence rate in patients treated with ASCs was 17.6 percent. Both treatments were well tolerated.

CONCLUSION

Administration of expanded ASCs (20 to 60 million cells) in combination with fibrin glue is an effective and safe treatment for complex perianal fistula and appears to achieve higher rates of healing than fibrin glue alone.

[Morphological changes of experimentally modelled pararectal fistula after application of the thrombofibrin gel]

Pararectal fistulas is the most frequently revealed proctological pathology, their rate constitutes 0.5-4% in the rectal diseases structure. We have proposed a new method of treatment of complex pararectal fistulas, using fibrin-gel, the procedure is simple and miniinvasive. In experiment on rabbits the artificial pararectal fistula was formed. Morphological changes under the influence of treatment were studied up on the 3rd, 7th and 10th days. While application of fibrin-gel the acceleration of epithelial cells and fistula channels regeneration was noted.

[Fistula-in-ano treatment a modo Jonesko using brace]

References to fistula-in-ano date to antiquity. Hippocrates made reference to surgical therapy for fistulous disease. The English surgeon John Arderne described fistulotomy and seton use in 1376. Despite 2500 years of experience, fistula-in-ano remains a perplexing surgical disease. Over the last 30 years, many authors have presented new techniques and case series in an effort to minimize recurrence rates and incontinence complication. We offer a new technique for seton placement using a brace.

Mucinous adenocarcinoma arising in an anorectal fistula

Mucinous adenocarcinoma in association with chronic anal fistula is a rare case in clinical practice. The aim of this article was to report a rare case of anal gland mucinous adenocarcinoma in a patient who was treated in the Hospital of Kaunas University of Medicine.

CASE REPORT

A 70-year-old male was treated for anorectal fistula in the surgical department. Four operations were performed for perineal abscess during the period of 15 years. During the period of 15 years, the patient complained of purulent secretion from the perineal abscess. After the last operation, anorectal fistula developed. Multiple biopsies and scrapings of the fistulous track were taken for histological examination. Histological examination revealed mucinous adenocarcinoma, G2. Subsequently, the patient underwent endoanal ultrasound, computed tomography scan, and colonoscopy. The computed tomography scan did not show pathology in the abdomen, but showed soft tissue induration at the site of anorectal fistula. Colonoscopy investigation did not show any pathology in the rectum and bowels. Endoanal ultrasound findings showed soft tissue induration at the site of anorectal fistula, no tumor in the rectum wall. The patient underwent abdominoperineal resection. Histological examination after abdominoperineal resection revealed anal duct mucinous adenocarcinoma pT2 N0 L0 V0 R0, G2. Metastases to the mesenteric lymph nodes were not detected. On the eighth day after abdominoperineal resection, the patient was discharged from the hospital for follow-up.

SUMMARY

Mucinous adenocarcinoma in anorectal fistula is a rare condition. If surgical treatment for perineal abscess or anorectal fistula is not successful for a long time, mucinous adenocarcinoma should be suspected.